Healthcare Provider Details

I. General information

NPI: 1043729965
Provider Name (Legal Business Name): GAVIN THEOFIELD LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2017
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 SAM NEWELL RD STE 100
MATTHEWS NC
28105-7593
US

IV. Provider business mailing address

1561 NUNNELLY LN APT 308
FORT MILL SC
29708-0098
US

V. Phone/Fax

Practice location:
  • Phone: 704-360-3637
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-5121
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC017506
License Number StateNC

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: