Healthcare Provider Details

I. General information

NPI: 1831619352
Provider Name (Legal Business Name): GABRIELLE FRANCIS CONRAD-AMLICKE MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2017
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 DUDLEY ST
ROXBURY MA
02119-2769
US

IV. Provider business mailing address

1940 COMMONWEALTH AVE APT 21
BRIGHTON MA
02135-5806
US

V. Phone/Fax

Practice location:
  • Phone: 203-470-5990
  • Fax:
Mailing address:
  • Phone: 781-292-2196
  • Fax: 781-292-2197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: