MEDICARE: GABRIEL ETHAN HORAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	22712	MD

General Provider Information

NPI Number	:	1053882480
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIEL ETHAN HORAN

Provider Business Mailing Address
First Line	:	HOPE HEALTH
Second Line	:	6707 WHITESTONE RD # 106
City	:	GWYNN OAK
State	:	MD
Zip	:	21207
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2401 BARE RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21209-1618
Country	:	US
Telephone Number	:	917-600-9289
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2018
Last Update Date	:	12/11/2018

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