Healthcare Provider Details

I. General information

NPI: 1114462504
Provider Name (Legal Business Name): GABRIELLE MACK LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2016
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16110 JAMAICA AVE 2ND FLOOR
JAMAICA NY
11432-6139
US

IV. Provider business mailing address

16110 JAMAICA AVE 2ND FLOOR
JAMAICA NY
11432-6139
US

V. Phone/Fax

Practice location:
  • Phone: 718-674-1000
  • Fax:
Mailing address:
  • Phone: 718-674-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number098480
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: