Healthcare Provider Details

I. General information

NPI: 1073864773
Provider Name (Legal Business Name): EVAN GAMBLE WEBSTER MA, LCAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2012
Last Update Date: 09/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4141 CARPENTER AVE 2ND FLOOR
BRONX NY
10466-2600
US

IV. Provider business mailing address

4141 CARPENTER AVE 2ND FLOOR
BRONX NY
10466-2600
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-9595
  • Fax: 718-920-6885
Mailing address:
  • Phone: 718-920-9595
  • Fax: 718-920-6885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number000850-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: