Provider Demographics
NPI:1780668111
Name:GAMBLE, ROBERT EDWARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EDWARD
Last Name:GAMBLE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 BOATNER RD STE 114
Mailing Address - Street 2:
Mailing Address - City:EGLIN AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32542-1302
Mailing Address - Country:US
Mailing Address - Phone:850-883-8600
Mailing Address - Fax:
Practice Address - Street 1:307 BOATNER RD STE 114
Practice Address - Street 2:
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542-1302
Practice Address - Country:US
Practice Address - Phone:850-883-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002886103T00000X
MI6801012516104100000X
MI6301002279103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801012516OtherSOCIAL WORKER LICENSE
GAPSY002886OtherPSYCHOLOGIST LICENSE
MI6301002279OtherPSYCHOLOGIST LICENSE
MIOM97220Medicare ID - Type UnspecifiedMEDICARE NUMBER