Healthcare Provider Details

I. General information

NPI: 1639973324
Provider Name (Legal Business Name): GABRIELLE VANDUSER LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2025
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 HARRISON ST
SYRACUSE NY
13210-2695
US

IV. Provider business mailing address

28 ELDERKIN AVE
CAMILLUS NY
13031-1024
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-3265
  • Fax:
Mailing address:
  • Phone: 315-367-8018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number126567
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: