Provider Demographics
NPI:1790482701
Name:MCGRADE, GABRIEL DANIEL
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:DANIEL
Last Name:MCGRADE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12208 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3800
Mailing Address - Country:US
Mailing Address - Phone:323-252-2685
Mailing Address - Fax:
Practice Address - Street 1:12208 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-3800
Practice Address - Country:US
Practice Address - Phone:323-252-2685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAY5610128OtherDRIVER LICENSE