1811083421 NPI number — MICHELE A GABOURY MSW

Table of content: MICHELE A GABOURY MSW (NPI 1811083421)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811083421 NPI number — MICHELE A GABOURY MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GABOURY
Provider First Name:
MICHELE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811083421
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20 MEETINGHOUSE ROAD
Provider Second Line Business Mailing Address:
PO BOX 1033
Provider Business Mailing Address City Name:
LITTLEOTN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-952-0150
Provider Business Mailing Address Fax Number:
978-952-6322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 MOUNT AUBURN STREET
Provider Second Line Business Practice Location Address:
HARVARD UNIVERSITY, CAMHS
Provider Business Practice Location Address City Name:
CAMBRIDGE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-495-2042
Provider Business Practice Location Address Fax Number:
617-496-6890
Provider Enumeration Date:
10/04/2006

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: 1041C0700X , with the licence number:  105122 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PO3284 . This is a "BC/BS PROVIDER NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 101867 . This is a "MAGELLAN PROVIDER NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 105122 . This is a "LICSW" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 5144002 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 766044 . This is a "TUFTS PROVIDER NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 216598 . This is a "MANAGED HEALTH NETWORK PR" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2073786 . This is a "CIGNA PROVIDER NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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