Provider Demographics
NPI:1487662474
Name:GAMBER, PHILIP MARK (MSW)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:MARK
Last Name:GAMBER
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23113
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48909-3113
Mailing Address - Country:US
Mailing Address - Phone:517-505-0610
Mailing Address - Fax:517-853-2993
Practice Address - Street 1:5000 NORTHWIND DR
Practice Address - Street 2:SUITE 100
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5044
Practice Address - Country:US
Practice Address - Phone:517-505-0610
Practice Address - Fax:517-853-2003
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010706031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P40790001Medicare ID - Type Unspecified