Healthcare Provider Details

I. General information

NPI: 1992337422
Provider Name (Legal Business Name): GABRIELLE L IBRAHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2020
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3408 PARK AVE
WANTAGH NY
11793-3702
US

IV. Provider business mailing address

1444 5TH AVE
BAY SHORE NY
11706-4147
US

V. Phone/Fax

Practice location:
  • Phone: 516-221-2123
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: