MEDICARE: GAYLE D GOLDBLATT LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	L3121	OR

General Provider Information

NPI Number	:	1912923848
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GAYLE D GOLDBLATT LCSW

Provider Business Mailing Address
First Line	:	1957 THOMPSON RD
Second Line	:
City	:	COOS BAY
State	:	OR
Zip	:	97420-2040
Country	:	US
Telephone Number	:	541-266-8575
Fax Number	:	541-269-7656

Provider Business Practice Location Address
First Line	:	1957 THOMPSON RD
Second Line	:
City	:	COOS BAY
State	:	OR
Zip	:	97420-2040
Country	:	US
Telephone Number	:	541-266-8575
Fax Number	:	541-269-7656

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	08/01/2013

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