Provider Demographics
NPI:1306172184
Name:VAN HORN, GAYLE (MSW, LCSW, LISW, LIP)
Entity type:Individual
Prefix:
First Name:GAYLE
Middle Name:
Last Name:VAN HORN
Suffix:
Gender:F
Credentials:MSW, LCSW, LISW, LIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12415 SHELLY PINES DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-1034
Mailing Address - Country:US
Mailing Address - Phone:704-596-5553
Mailing Address - Fax:
Practice Address - Street 1:12415 SHELLY PINES DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-1034
Practice Address - Country:US
Practice Address - Phone:704-608-3760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-28
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0051581041C0700X, 101YM0800X
SC103651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC10365OtherLICENSED INDEPENDENT SOCIAL WORKER
NC6006204Medicaid