Provider Demographics
NPI:1174805709
Name:GOTTESMAN, BENJAMIN (PSYD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:GOTTESMAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:291 CARLTON TER
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-3403
Mailing Address - Country:US
Mailing Address - Phone:914-236-0832
Mailing Address - Fax:
Practice Address - Street 1:121 CEDAR LN STE 102
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4457
Practice Address - Country:US
Practice Address - Phone:914-236-0832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021419103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent