Provider Demographics
NPI:1619260957
Name:GUDIS, JACQUELINE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GUDIS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 E 31ST ST
Mailing Address - Street 2:APT. #5D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6814
Mailing Address - Country:US
Mailing Address - Phone:323-833-7863
Mailing Address - Fax:
Practice Address - Street 1:104 E 31ST ST
Practice Address - Street 2:APT. #5D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6814
Practice Address - Country:US
Practice Address - Phone:323-833-7863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-19
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18261235Z00000X
NY021942235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist