Provider Demographics
NPI:1295126365
Name:GIMBRONE, CRAIG
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:GIMBRONE
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 1:3815 WASHINGTON STREET #2
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAINS
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4917
Mailing Address - Country:US
Mailing Address - Phone:617-983-5800
Mailing Address - Fax:
Practice Address - Street 1:3815 WASHINGTON STREET #2
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAINS
Practice Address - State:MA
Practice Address - Zip Code:02130-4917
Practice Address - Country:US
Practice Address - Phone:617-983-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-11
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist