Provider Demographics
NPI:1891907358
Name:GUMMELT, JUDY CHANG (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JUDY
Middle Name:CHANG
Last Name:GUMMELT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:JUDY
Other - Middle Name:P
Other - Last Name:CHANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:16 E 79TH ST
Mailing Address - Street 2:4-1
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-0150
Mailing Address - Country:US
Mailing Address - Phone:212-861-4783
Mailing Address - Fax:
Practice Address - Street 1:16 E 79TH ST
Practice Address - Street 2:4-1
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-0150
Practice Address - Country:US
Practice Address - Phone:212-861-4783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010366-1103TC0700X
CAPSY18086103TC0700X
OR1836103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP18086Medicare ID - Type Unspecified
NYA 300001244Medicare UPIN