Provider Demographics
NPI:1598271876
Name:GAMBOA, DEFNY
Entity Type:Individual
Prefix:
First Name:DEFNY
Middle Name:
Last Name:GAMBOA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 FRANKLIN AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10553-1714
Mailing Address - Country:US
Mailing Address - Phone:518-253-9474
Mailing Address - Fax:
Practice Address - Street 1:2901 CAMPUS RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-2153
Practice Address - Country:US
Practice Address - Phone:518-253-9474
Practice Address - Fax:518-253-9474
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY083215104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty