Healthcare Provider Details

I. General information

NPI: 1275895864
Provider Name (Legal Business Name): GABRIELLE MARIE KILGORE LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2012
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 W PADONIA RD STE C348
TIMONIUM MD
21093-2243
US

IV. Provider business mailing address

3105 ORLANDO AVE
BALTIMORE MD
21234-7834
US

V. Phone/Fax

Practice location:
  • Phone: 443-286-9613
  • Fax:
Mailing address:
  • Phone: 443-286-9613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16252
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: