Healthcare Provider Details

I. General information

NPI: 1588389852
Provider Name (Legal Business Name): GABRIELLE MATIJOSAITIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 01/14/2024
Certification Date: 01/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S CHESTER RD STE 105
SWARTHMORE PA
19081-1800
US

IV. Provider business mailing address

513 N OLD MIDDLETOWN RD
MEDIA PA
19063-4429
US

V. Phone/Fax

Practice location:
  • Phone: 610-203-6102
  • Fax:
Mailing address:
  • Phone: 610-203-6102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberQ1-0012398
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW022981
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: