Healthcare Provider Details

I. General information

NPI: 1093952301
Provider Name (Legal Business Name): GENTLE GROWTH THERAPEUTIC SERVICES, LCSW, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2009
Last Update Date: 06/20/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 NORTH STATE ROAD #202
BRIARCLIFF MANOR NY
10510
US

IV. Provider business mailing address

1872 PLEASANTVILLE ROAD, #129
BRIARCLIFF MANOR NY
10510
US

V. Phone/Fax

Practice location:
  • Phone: 914-471-2632
  • Fax: 914-944-0595
Mailing address:
  • Phone: 914-471-2632
  • Fax: 914-944-0595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberLCSW 052250
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. LETITIA VICTORIA COBURN
Title or Position: OWNER
Credential: LCSW
Phone: 914-471-2632