Provider Demographics
NPI:1710584933
Name:GAMBINO, STEFANIE ANNE (LMT)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:ANNE
Last Name:GAMBINO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 AVALON PINES DR
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-5162
Mailing Address - Country:US
Mailing Address - Phone:772-579-8548
Mailing Address - Fax:
Practice Address - Street 1:18 WEEKS ST
Practice Address - Street 2:
Practice Address - City:BLUE POINT
Practice Address - State:NY
Practice Address - Zip Code:11715-1513
Practice Address - Country:US
Practice Address - Phone:631-419-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032264-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist