Provider Demographics
NPI:1629129366
Name:GABRUK, LINDA
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:GABRUK
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 1:63 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4042
Mailing Address - Country:US
Mailing Address - Phone:508-559-6699
Mailing Address - Fax:508-559-5073
Practice Address - Street 1:63 MAIN ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4042
Practice Address - Country:US
Practice Address - Phone:508-894-3204
Practice Address - Fax:508-559-1158
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10226831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP0672301Medicare PIN