Provider Demographics
NPI:1447015011
Name:FIDIS, GABRIELLE (LCAT, RDT)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:FIDIS
Suffix:
Gender:F
Credentials:LCAT, RDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3418 44TH ST APT 1F
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11101-1252
Mailing Address - Country:US
Mailing Address - Phone:516-319-2881
Mailing Address - Fax:
Practice Address - Street 1:3418 44TH ST APT 1F
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11101-1252
Practice Address - Country:US
Practice Address - Phone:516-319-2881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002944101200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101200000XBehavioral Health & Social Service ProvidersDrama Therapist