Provider Demographics
NPI:1356493613
Name:KAILBOURNE, GAIL PATRICIA (MS CSP, LPC)
Entity Type:Individual
Prefix:MRS
First Name:GAIL
Middle Name:PATRICIA
Last Name:KAILBOURNE
Suffix:
Gender:F
Credentials:MS CSP, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2714 IDLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-4729
Mailing Address - Country:US
Mailing Address - Phone:704-838-4040
Mailing Address - Fax:704-838-7668
Practice Address - Street 1:2714 IDLEWOOD LN
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-4729
Practice Address - Country:US
Practice Address - Phone:704-838-4040
Practice Address - Fax:704-838-7668
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLPC-5113103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103337Medicaid