Healthcare Provider Details

I. General information

NPI: 1942505177
Provider Name (Legal Business Name): GAIL BRAXTON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2011
Last Update Date: 03/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

741 BROADWAY
NEWARK NJ
07104
US

IV. Provider business mailing address

741 BROADWAY
NEWARK NJ
07104
US

V. Phone/Fax

Practice location:
  • Phone: 973-675-1900
  • Fax: 973-676-1396
Mailing address:
  • Phone: 973-675-1900
  • Fax: 973-676-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR034474-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: