Basic Information
Provider Information | |||||||||
NPI: | 1780668111 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GAMBLE | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | EDWARD | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 307 BOATNER RD STE 114 | ||||||||
Address2: |   | ||||||||
City: | EGLIN AFB | ||||||||
State: | FL | ||||||||
PostalCode: | 325421302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8508838600 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 307 BOATNER RD STE 114 | ||||||||
Address2: |   | ||||||||
City: | EGLIN AFB | ||||||||
State: | FL | ||||||||
PostalCode: | 325421302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8508838600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/30/2005 | ||||||||
LastUpdateDate: | 05/06/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/06/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PSY002886 | GA | N |   | Behavioral Health & Social Service Providers | Psychologist |   | 104100000X | 6801012516 | MI | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 103T00000X | 6301002279 | MI | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 6801012516 | 01 | MI | SOCIAL WORKER LICENSE | OTHER | PSY002886 | 01 | GA | PSYCHOLOGIST LICENSE | OTHER | 6301002279 | 01 | MI | PSYCHOLOGIST LICENSE | OTHER |