Healthcare Provider Details

I. General information

NPI: 1609403401
Provider Name (Legal Business Name): GABRIEL TOBIN SMITH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 03/24/2020
Certification Date: 03/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 OLD WEST CHESTER PIKE
HAVERTOWN PA
19083-2712
US

IV. Provider business mailing address

2036 MOUNT VERNON ST APT 3F
PHILADELPHIA PA
19130-3278
US

V. Phone/Fax

Practice location:
  • Phone: 484-454-8700
  • Fax:
Mailing address:
  • Phone: 260-466-4470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW020694
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: