Healthcare Provider Details

I. General information

NPI: 1235131293
Provider Name (Legal Business Name): GAYLE BROMBERG LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 THOMAS JOHNSON DR STE 210
FREDERICK MD
21702-4354
US

IV. Provider business mailing address

170 THOMAS JOHNSON DR STE 210
FREDERICK MD
21702-4354
US

V. Phone/Fax

Practice location:
  • Phone: 301-695-8390
  • Fax: 301-694-7906
Mailing address:
  • Phone: 301-695-8390
  • Fax: 301-694-7906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number04118
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: