Provider Demographics
NPI:1679054340
Name:GAYLE, NASTACIA
Entity Type:Individual
Prefix:
First Name:NASTACIA
Middle Name:
Last Name:GAYLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14590 222ND ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11413-3428
Mailing Address - Country:US
Mailing Address - Phone:917-396-8497
Mailing Address - Fax:
Practice Address - Street 1:14590 222ND ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11413-3428
Practice Address - Country:US
Practice Address - Phone:917-396-8497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRF08151YMedicaid