Provider Demographics
NPI:1073864773
Name:WEBSTER, EVAN GAMBLE (MA, LCAT)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:GAMBLE
Last Name:WEBSTER
Suffix:
Gender:M
Credentials:MA, LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4141 CARPENTER AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-2600
Mailing Address - Country:US
Mailing Address - Phone:718-920-9595
Mailing Address - Fax:718-920-6885
Practice Address - Street 1:4141 CARPENTER AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-2600
Practice Address - Country:US
Practice Address - Phone:718-920-9595
Practice Address - Fax:718-920-6885
Is Sole Proprietor?:No
Enumeration Date:2012-09-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000850-1221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist