Healthcare Provider Details

I. General information

NPI: 1528280757
Provider Name (Legal Business Name): CHRISTINE ANGELA GEPHART LCSW-R
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 02/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 MAIN ST
LE ROY NY
14482-1444
US

IV. Provider business mailing address

71 MAIN ST
LE ROY NY
14482-1444
US

V. Phone/Fax

Practice location:
  • Phone: 585-502-6025
  • Fax: 585-502-5213
Mailing address:
  • Phone: 585-502-6025
  • Fax: 585-502-5213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR055014-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: