=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053882480
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GABRIEL ETHAN HORAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2018
-----------------------------------------------------
Last Update Date | 12/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2401 BARE RD
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21209-1618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-600-9289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | HOPE HEALTH 6707 WHITESTONE RD # 106
-----------------------------------------------------
City | GWYNN OAK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 22712
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------