Provider Demographics
NPI:1457097628
Name:GWAK, ANGELA S (MFT, PHD)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:S
Last Name:GWAK
Suffix:
Gender:F
Credentials:MFT, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E 23RD ST STE 606
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-4511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 E 23RD ST STE 606
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4511
Practice Address - Country:US
Practice Address - Phone:212-884-1903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-10
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026238103TC1900X
NYP114725390200000X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program