MEDICARE: GABRIEL LYNN FOSSETT LSW

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	150.129129	IL

General Provider Information

NPI Number	:	1750223830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIEL LYNN FOSSETT LSW

Provider Business Mailing Address
First Line	:	325 IL-2
Second Line	:
City	:	DIXON
State	:	IL
Zip	:	61021
Country	:	US
Telephone Number	:	815-440-7487
Fax Number	:

Provider Business Practice Location Address
First Line	:	325 IL-2
Second Line	:
City	:	DIXON
State	:	IL
Zip	:	61021
Country	:	US
Telephone Number	:	815-440-7487
Fax Number	:

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

Provider Enumeration Date	:	04/07/2026
Last Update Date	:	04/07/2026

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