Provider Demographics
NPI:1093360703
Name:BALSAM, GAVRIEL YEHUDAH
Entity Type:Individual
Prefix:
First Name:GAVRIEL
Middle Name:YEHUDAH
Last Name:BALSAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5309 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-1523
Mailing Address - Country:US
Mailing Address - Phone:718-705-5190
Mailing Address - Fax:
Practice Address - Street 1:5309 18TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-1523
Practice Address - Country:US
Practice Address - Phone:718-705-5190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker