Provider Demographics
NPI:1235131293
Name:BROMBERG, GAYLE (LCSW-C)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:
Last Name:BROMBERG
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 THOMAS JOHNSON DR
Mailing Address - Street 2:STE 210
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4354
Mailing Address - Country:US
Mailing Address - Phone:301-695-8390
Mailing Address - Fax:301-694-7906
Practice Address - Street 1:170 THOMAS JOHNSON DR
Practice Address - Street 2:STE 210
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4354
Practice Address - Country:US
Practice Address - Phone:301-695-8390
Practice Address - Fax:301-694-7906
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD041181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD239102OtherMAMSI
MD922CMedicare ID - Type Unspecified