Provider Demographics
NPI:1245711266
Name:GEWIRTZ, MINDY L (PHD)
Entity type:Individual
Prefix:DR
First Name:MINDY
Middle Name:L
Last Name:GEWIRTZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BALSAM CT APT 19
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07014-1350
Mailing Address - Country:US
Mailing Address - Phone:617-803-2268
Mailing Address - Fax:
Practice Address - Street 1:5 BALSAM CT APT 19
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07014-1350
Practice Address - Country:US
Practice Address - Phone:617-803-2268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1052821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA105282OtherMASS HEALTH NON BILLING PROVIDER