Healthcare Provider Details

I. General information

NPI: 1184487936
Provider Name (Legal Business Name): MADELINE GEBHARD LICSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2024
Last Update Date: 02/05/2024
Certification Date: 02/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10799 FALLING WATER LN UNIT D
WOODBURY MN
55129-5263
US

IV. Provider business mailing address

10799 FALLING WATER LN UNIT D
WOODBURY MN
55129-5263
US

V. Phone/Fax

Practice location:
  • Phone: 323-333-9511
  • Fax:
Mailing address:
  • Phone: 323-333-9511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number20482
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberCSW.09928484
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number20482
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: