1003037607 NPI number — RENEE GAMBOL

Table of content: RENEE GAMBOL (NPI 1003037607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003037607 NPI number — RENEE GAMBOL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAMBOL
Provider First Name:
RENEE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GAMBOL
Provider Other First Name:
RENEE
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC, MA, MDV. CASAC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1003037607
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
385 BAYVIEW AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INWOOD
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11096
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-337-6850
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1329 BEACH CHANNEL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAR ROCKAWAY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11691
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-337-6850
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/01/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  1891 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 101YA0400X , with the licence number: 11346 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)