Provider Demographics
NPI:1629877170
Name:GITCHEL, BRENT D
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:D
Last Name:GITCHEL
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 1:4905 HICKORY WOODS DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-9165
Mailing Address - Country:US
Mailing Address - Phone:336-339-4834
Mailing Address - Fax:
Practice Address - Street 1:1617 S HAWTHORNE RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4127
Practice Address - Country:US
Practice Address - Phone:336-794-6058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-10
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCADC-31779101YA0400X
NCLCAS-30593101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)