Provider Demographics
NPI:1588869184
Name:GILBERT, THEODORE JR
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:GILBERT
Suffix:JR
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 1:635 COX RD STE B
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-3441
Mailing Address - Country:US
Mailing Address - Phone:704-691-7561
Mailing Address - Fax:
Practice Address - Street 1:13420 MICHAEL LYNN RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28278-7640
Practice Address - Country:US
Practice Address - Phone:219-730-3976
Practice Address - Fax:219-730-3976
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NCP010172101YM0800X
NCC0118751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health