Healthcare Provider Details

I. General information

NPI: 1235671058
Provider Name (Legal Business Name): KAITLIN GEBHARDT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2016
Last Update Date: 11/16/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 LILAC RD
WESTHAMPTON BEACH NY
11978-2008
US

IV. Provider business mailing address

5 TULIP CT
MORICHES NY
11955-1901
US

V. Phone/Fax

Practice location:
  • Phone: 631-831-5489
  • Fax:
Mailing address:
  • Phone: 631-831-5489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number092146
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: