Provider Demographics
NPI:1710067426
Name:GOTTFRIED, DIANE CAROL (PHD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:CAROL
Last Name:GOTTFRIED
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 POWERS ST
Mailing Address - Street 2:APT. 1F
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-5027
Mailing Address - Country:US
Mailing Address - Phone:718-599-3051
Mailing Address - Fax:
Practice Address - Street 1:760 BROADWAY
Practice Address - Street 2:ROOM 2B-151
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-5317
Practice Address - Country:US
Practice Address - Phone:718-486-2788
Practice Address - Fax:718-630-3250
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016835-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical