Basic Information
Provider Information | |||||||||
NPI: | 1003037607 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GAMBOL | ||||||||
FirstName: | RENEE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GAMBOL | ||||||||
OtherFirstName: | RENEE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LPC, MA, MDV. CASAC | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 385 BAYVIEW AVE | ||||||||
Address2: |   | ||||||||
City: | INWOOD | ||||||||
State: | NY | ||||||||
PostalCode: | 11096 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7183376850 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1329 BEACH CHANNEL DRIVE | ||||||||
Address2: |   | ||||||||
City: | FAR ROCKAWAY | ||||||||
State: | NY | ||||||||
PostalCode: | 11691 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7183376850 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 1891 | OK | X |   | Behavioral Health & Social Service Providers | Counselor |   | 101YA0400X | 11346 | NY | X |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.