Provider Demographics
NPI:1669097325
Name:CHUDNOW, GABRIELLE (MA)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:CHUDNOW
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 STATE RD # 313
Mailing Address - Street 2:
Mailing Address - City:VINEYARD HAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02568-5695
Mailing Address - Country:US
Mailing Address - Phone:508-684-8620
Mailing Address - Fax:
Practice Address - Street 1:111 EDGARTOWN RD
Practice Address - Street 2:
Practice Address - City:VINEYARD HAVEN
Practice Address - State:MA
Practice Address - Zip Code:02568-5699
Practice Address - Country:US
Practice Address - Phone:508-684-8620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-09
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1669097325Medicaid