Provider Demographics
NPI:1629483599
Name:GESHER LLC
Entity Type:Organization
Organization Name:GESHER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DREYFUS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:203-527-8172
Mailing Address - Street 1:4 CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06710-1724
Mailing Address - Country:US
Mailing Address - Phone:203-527-8172
Mailing Address - Fax:203-889-0991
Practice Address - Street 1:4 CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06710-1724
Practice Address - Country:US
Practice Address - Phone:203-527-8172
Practice Address - Fax:203-889-0991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-30
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037755207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008052316Medicaid
CT037755OtherMEDICAL LICENSE
CT037755OtherMEDICAL LICENSE
CT037755OtherMEDICAL LICENSE
CTF95435Medicare UPIN