Provider Demographics
NPI:1902548852
Name:SIMON, GAVRIELLE BETH (LSW)
Entity Type:Individual
Prefix:
First Name:GAVRIELLE
Middle Name:BETH
Last Name:SIMON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:GAVRIELLE
Other - Middle Name:BETH
Other - Last Name:CANTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:143 HAMMELL PL
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07607-1869
Mailing Address - Country:US
Mailing Address - Phone:201-647-5226
Mailing Address - Fax:
Practice Address - Street 1:4 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-5237
Practice Address - Country:US
Practice Address - Phone:201-565-2920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06246500104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker