Provider Demographics
NPI:1376894899
Name:ANDERSON, GABRIEL (CASAC)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 QUEENS BLVD
Mailing Address - Street 2:307
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-3638
Mailing Address - Country:US
Mailing Address - Phone:718-275-4174
Mailing Address - Fax:718-275-4280
Practice Address - Street 1:10470 QUEENS BLVD
Practice Address - Street 2:307
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-3638
Practice Address - Country:US
Practice Address - Phone:718-275-4174
Practice Address - Fax:718-275-4280
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS129101YA0400X
NY29993101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)