Healthcare Provider Details

I. General information

NPI: 1033727128
Provider Name (Legal Business Name): MAEVON ELLIOT GUMBLE MMT, MT-BC, LPC
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5840 ELLSWORTH AVE #100
PITTSBURGH PA
15232-1712
US

IV. Provider business mailing address

5840 ELLSWORTH AVE STE 100
PITTSBURGH PA
15232-1712
US

V. Phone/Fax

Practice location:
  • Phone: 412-223-7067
  • Fax: 412-223-9867
Mailing address:
  • Phone: 412-223-7067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number12781
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License NumberMUS.000041
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPCO16736
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: