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General NPI Number Information
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NPI Number | 1043729965
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Entity Type | Individual
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Provider Name | GAVIN THEOFIELD LCSW
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Gender | Male
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Dates
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Enumeration Date | 09/22/2017
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Last Update Date | 09/17/2024
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Provider Practice Location Address
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Address Line | 855 SAM NEWELL RD STE 100
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City | MATTHEWS
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State | NC
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Zip | 28105-7593
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Country | US
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Telephone | 704-360-3637
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Fax |
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Provider Business Mailing Address
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Address Line | 1561 NUNNELLY LN APT 308
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City | FORT MILL
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State | SC
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Zip | 29708-0098
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW-5121
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License Number State | HI
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C017506
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License Number State | NC
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