Provider Demographics
NPI:1942510052
Name:GAMBOA, BRIAN C
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:C
Last Name:GAMBOA
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 1:3 ASHLAWN RD
Mailing Address - Street 2:
Mailing Address - City:ASSONET
Mailing Address - State:MA
Mailing Address - Zip Code:02702-1105
Mailing Address - Country:US
Mailing Address - Phone:508-933-5205
Mailing Address - Fax:877-308-2202
Practice Address - Street 1:3 ASHLAWN RD
Practice Address - Street 2:
Practice Address - City:ASSONET
Practice Address - State:MA
Practice Address - Zip Code:02702-1105
Practice Address - Country:US
Practice Address - Phone:508-933-5205
Practice Address - Fax:877-308-2202
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-08
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health