Provider Demographics
NPI:1972931970
Name:AVILES, GWEN GLORIA
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:GLORIA
Last Name:AVILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:GLORIA
Other - Last Name:ZIEDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SPECIAL INSTRUCTOR
Mailing Address - Street 1:357 79TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-3609
Mailing Address - Country:US
Mailing Address - Phone:718-730-0264
Mailing Address - Fax:
Practice Address - Street 1:357 79TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3609
Practice Address - Country:US
Practice Address - Phone:718-730-0264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY401459101103K00000X
NY5921180121174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY592180121OtherNYS CERTIFICATION