Provider Demographics
NPI:1770610644
Name:GILLMAN, HEATHER (PSYD)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:
Last Name:GILLMAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 SOUTH DR
Mailing Address - Street 2:
Mailing Address - City:WALDEN
Mailing Address - State:NY
Mailing Address - Zip Code:12586-2306
Mailing Address - Country:US
Mailing Address - Phone:516-236-8974
Mailing Address - Fax:
Practice Address - Street 1:157 SOUTH DR
Practice Address - Street 2:
Practice Address - City:WALDEN
Practice Address - State:NY
Practice Address - Zip Code:12586-2306
Practice Address - Country:US
Practice Address - Phone:516-236-8974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016474-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02909204Medicaid
NYVN4461Medicare PIN