Provider Demographics
NPI:1174220438
Name:GAMBOA, ROBERT R
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:R
Last Name:GAMBOA
Suffix:
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 1:1435 N EXPRESSWAY STE 301
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-9014
Mailing Address - Country:US
Mailing Address - Phone:770-358-5252
Mailing Address - Fax:
Practice Address - Street 1:713 ANDREWS DR
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-4524
Practice Address - Country:US
Practice Address - Phone:770-358-5252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC008821101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor