Provider Demographics
NPI:1285690040
Name:EL-HAGE BOUTROUS, GABRIEL Y (PHD)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:Y
Last Name:EL-HAGE BOUTROUS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4565 DRESSLER RD NW
Mailing Address - Street 2:SUITE LL 21
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2549
Mailing Address - Country:US
Mailing Address - Phone:330-491-9700
Mailing Address - Fax:330-491-9730
Practice Address - Street 1:4565 DRESSLER RD NW
Practice Address - Street 2:SUITE LL 21
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2549
Practice Address - Country:US
Practice Address - Phone:330-491-9700
Practice Address - Fax:330-491-9730
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3718103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0685290Medicaid
OH0685290Medicaid
CP07474Medicare PIN