Provider Demographics
NPI:1003037607
Name:GAMBOL, RENEE
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:GAMBOL
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:RENEE
Other - Middle Name:
Other - Last Name:GAMBOL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC, MA, MDV CASAC
Mailing Address - Street 1:385 BAYVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:INWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11096
Mailing Address - Country:US
Mailing Address - Phone:718-337-6850
Mailing Address - Fax:
Practice Address - Street 1:1329 BEACH CHANNEL DRIVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691
Practice Address - Country:US
Practice Address - Phone:718-337-6850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1891101Y00000X
NY11346101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)