Basic Information
| Provider Information | |||||||||
| NPI: | 1235399064 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOSSY | ||||||||
| FirstName: | DORIAN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 CAREY RD | ||||||||
| Address2: | |||||||||
| City: | QUEENSBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128047880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187610300 | ||||||||
| FaxNumber: | 5188242388 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 ADIRONDACK DR STE 2 | ||||||||
| Address2: | |||||||||
| City: | TICONDEROGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128839334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185856708 | ||||||||
| FaxNumber: | 5185853260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2008 | ||||||||
| LastUpdateDate: | 11/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 079776-1 | NY | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 079776 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 02996789 | 05 | NY | MEDICAID |