Basic Information
Provider Information | |||||||||
NPI: | 1639138985 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GESUELLE-HART | ||||||||
FirstName: | SANDRA | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LICSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 31 HALL DR | ||||||||
Address2: | VALLEY MEDICAL GROUP, PC | ||||||||
City: | AMHERST | ||||||||
State: | MA | ||||||||
PostalCode: | 010022751 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4132564441 | ||||||||
FaxNumber: | 4132564412 | ||||||||
Practice Location | |||||||||
Address1: | 31 HALL DR | ||||||||
Address2: | AMHERST MEDICAL CENTER | ||||||||
City: | AMHERST | ||||||||
State: | MA | ||||||||
PostalCode: | 010022751 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4132568561 | ||||||||
FaxNumber: | 4132564412 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/23/2006 | ||||||||
LastUpdateDate: | 06/07/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1024506 | MA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 102450 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 800011935 | 01 | MA | RAILROAD MEDICARE | OTHER | P07225 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | 1295026 | 01 | MA | FALLON | OTHER | 269128000 | 01 | MA | MAGELLAN BEHAVIORAL HEALT | OTHER | 28635 | 01 | MA | HEALTH NEW ENGLAND | OTHER | 2073027 | 01 | MA | CIGNA BEHAVIORAL HEALTH | OTHER |