Healthcare Provider Details

I. General information

NPI: 1851006332
Provider Name (Legal Business Name): RYVER DAWN GAMBLE LLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2023
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 E BIG BEAVER RD
TROY MI
48083-1426
US

IV. Provider business mailing address

625 E BIG BEAVER RD
TROY MI
48083-1426
US

V. Phone/Fax

Practice location:
  • Phone: 586-863-4000
  • Fax:
Mailing address:
  • Phone: 586-863-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451025131
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: