Provider Demographics
NPI:1790866721
Name:GIBBONS, JUDITH (PHD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:GIBBONS
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 1:352 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-2330
Mailing Address - Country:US
Mailing Address - Phone:212-675-7549
Mailing Address - Fax:212-255-2363
Practice Address - Street 1:51 5TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-4320
Practice Address - Country:US
Practice Address - Phone:212-675-7549
Practice Address - Fax:212-255-2363
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY08183103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01734303Medicaid
NYV55181Medicare ID - Type Unspecified