Provider Demographics
NPI:1528209095
Name:GAMBLE, MINNETTE KATHLEEN (MPA, SPADA, LLMSW)
Entity Type:Individual
Prefix:MS
First Name:MINNETTE
Middle Name:KATHLEEN
Last Name:GAMBLE
Suffix:
Gender:F
Credentials:MPA, SPADA, LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:MI
Mailing Address - Zip Code:49345-1310
Mailing Address - Country:US
Mailing Address - Phone:616-322-6655
Mailing Address - Fax:
Practice Address - Street 1:168 MAPLE ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:MI
Practice Address - Zip Code:49345-1310
Practice Address - Country:US
Practice Address - Phone:616-685-0985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-13
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010810741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI32-0246857Medicaid