Provider Demographics
NPI:1841858800
Name:IDEN, GABRIELLE JOHANNA (LGSW)
Entity type:Individual
Prefix:MRS
First Name:GABRIELLE
Middle Name:JOHANNA
Last Name:IDEN
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:GABRIELLE
Other - Middle Name:JOHANNA
Other - Last Name:MCMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:55 MERIDIAN PKWY
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25404-5422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 EMMETT ROUSCH DR
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-6313
Practice Address - Country:US
Practice Address - Phone:304-901-2070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00945505101YA0400X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVBP00945505OtherWV BORAD OF SOCIAL WORK