Provider Demographics
NPI:1598967614
Name:GAUTREAU, EMMANUEL (MA, EDM)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:
Last Name:GAUTREAU
Suffix:
Gender:M
Credentials:MA, EDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 DECATUR LN
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-2509
Mailing Address - Country:US
Mailing Address - Phone:631-676-6504
Mailing Address - Fax:631-389-2580
Practice Address - Street 1:2534 STEINWAY ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-3702
Practice Address - Country:US
Practice Address - Phone:718-777-5243
Practice Address - Fax:718-777-5250
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101Y00000X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool