Provider Demographics
| NPI: | 1205936093 |
|---|---|
| Name: | GOURDINE, VANESSA (APN-C, PSYD) |
| Entity type: | Individual |
| Prefix: | DR |
| First Name: | VANESSA |
| Middle Name: | |
| Last Name: | GOURDINE |
| Suffix: | |
| Gender: | F |
| Credentials: | APN-C, PSYD |
| Other - Prefix: | |
| Other - First Name: | |
| Other - Middle Name: | |
| Other - Last Name: | |
| Other - Suffix: | |
| Other - Last Name Type: | |
| Other - Credentials: | |
| Mailing Address - Street 1: | PO BOX 746 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | FRANKLIN LAKES |
| Mailing Address - State: | NJ |
| Mailing Address - Zip Code: | 07417-0746 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 201-488-6678 |
| Mailing Address - Fax: | 201-342-4346 |
| Practice Address - Street 1: | 83 SUMMIT AVE |
| Practice Address - Street 2: | |
| Practice Address - City: | HACKENSACK |
| Practice Address - State: | NJ |
| Practice Address - Zip Code: | 07601-1262 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 201-488-6678 |
| Practice Address - Fax: | 201-342-4346 |
| Is Sole Proprietor?: | No |
| Enumeration Date: | 2006-09-22 |
| Last Update Date: | 2022-09-26 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| NJ | 35SIO00563500 | 102L00000X, 102L00000X |
| NJ | 35SI00263500 | 103T00000X, 103TA0400X, 103TC0700X, 103TC2200X, 103TH0100X |
| NJ | 26NJ00080100 | 363LF0000X, 364SP0810X, 363LP0808X, 364SP0807X, 363LW0102X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization |
|---|---|---|---|---|
| Yes | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health |
| No | 102L00000X | Behavioral Health & Social Service Providers | Psychoanalyst | |
| No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | |
| No | 103TA0400X | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) |
| No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical |
| No | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
| No | 103TH0100X | Behavioral Health & Social Service Providers | Psychologist | Health Service |
| No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
| No | 364SP0810X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psychiatric/Mental Health, Child & Family |
| No | 364SP0807X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psychiatric/Mental Health, Child & Adolescent |
| No | 363LW0102X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
