Provider Demographics
NPI:1366186249
Name:GOURLAY, CASSANDRA M
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:M
Last Name:GOURLAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 W MOMBASHA RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-5329
Mailing Address - Country:US
Mailing Address - Phone:845-624-1366
Mailing Address - Fax:
Practice Address - Street 1:2290 PALISADES CENTER DR
Practice Address - Street 2:
Practice Address - City:WEST NYACK
Practice Address - State:NY
Practice Address - Zip Code:10994-6402
Practice Address - Country:US
Practice Address - Phone:845-624-1366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225CX0006XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorOrientation and Mobility Training Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
22895OtherCERTIFICATION #