Provider Demographics
NPI:1790701043
Name:GUNDLE, SARAH SHOSHANA (PSYD)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:SHOSHANA
Last Name:GUNDLE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 W 24TH ST
Mailing Address - Street 2:SUITE 1F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-1351
Mailing Address - Country:US
Mailing Address - Phone:646-256-9233
Mailing Address - Fax:
Practice Address - Street 1:450 W 24TH ST
Practice Address - Street 2:SUITE 1F
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-1351
Practice Address - Country:US
Practice Address - Phone:646-256-9233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016292103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY016292Medicaid
NY016292Medicaid
NYVM8191Medicare ID - Type UnspecifiedMEDICARE