Provider Demographics
NPI:1104060243
Name:GAMBILL, MARY LOUISE (CLINICAL INTERN)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOUISE
Last Name:GAMBILL
Suffix:
Gender:F
Credentials:CLINICAL INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-2838
Mailing Address - Country:US
Mailing Address - Phone:937-223-3446
Mailing Address - Fax:937-223-3484
Practice Address - Street 1:301 E 6TH ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-2838
Practice Address - Country:US
Practice Address - Phone:937-223-3446
Practice Address - Fax:937-223-3484
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0600943TRNE1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical