Healthcare Provider Details

I. General information

NPI: 1104640432
Provider Name (Legal Business Name): ANDREW SCOTT GELBURD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2024
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

962 SAMUEL ST
LOUISVILLE KY
40204-2459
US

IV. Provider business mailing address

962 SAMUEL ST
LOUISVILLE KY
40204-2459
US

V. Phone/Fax

Practice location:
  • Phone: 717-571-2487
  • Fax:
Mailing address:
  • Phone: 717-571-2487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number259511
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: