Provider Demographics
NPI:1417609058
Name:EDIDIN, GABRIELLE H (MSW)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:H
Last Name:EDIDIN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 CARLISLE BLVD NE STE 105
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-1680
Mailing Address - Country:US
Mailing Address - Phone:505-652-2535
Mailing Address - Fax:
Practice Address - Street 1:3150 CARLISLE BLVD NE STE 110
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1681
Practice Address - Country:US
Practice Address - Phone:505-652-2535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-123061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM15492053OtherCAQH