Healthcare Provider Details

I. General information

NPI: 1720165574
Provider Name (Legal Business Name): LARRY ANTHONY GAMBLE L.C.S.W.-C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 TWINBROOK PKWY STE 2
ROCKVILLE MD
20851-1499
US

IV. Provider business mailing address

14127 YORKSHIRE WOODS DR
SILVER SPRING MD
20906-2872
US

V. Phone/Fax

Practice location:
  • Phone: 240-281-4513
  • Fax:
Mailing address:
  • Phone: 240-777-1444
  • Fax: 240-777-3381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number09477
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: