Provider Demographics
NPI:1760787568
Name:WICHROWSKI, GAYLEN PALMA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:GAYLEN
Middle Name:PALMA
Last Name:WICHROWSKI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:GAYLEN
Other - Middle Name:ANNE
Other - Last Name:PALMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:70 MALTA AVE
Mailing Address - Street 2:
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-1529
Mailing Address - Country:US
Mailing Address - Phone:518-884-7195
Mailing Address - Fax:518-884-7101
Practice Address - Street 1:210 BALLSTON AVE
Practice Address - Street 2:
Practice Address - City:BALLSTON SPA
Practice Address - State:NY
Practice Address - Zip Code:12020-3606
Practice Address - Country:US
Practice Address - Phone:518-884-7200
Practice Address - Fax:518-884-7234
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR-033565174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist