MEDICARE: GABRIELLE COOLIDGE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	90288	TX
2	101Y00000X	Counselor	90288	TX

General Provider Information

NPI Number	:	1306670443
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIELLE COOLIDGE

Provider Business Mailing Address
First Line	:	1300 S PLEASANT VALLEY RD APT 136
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78741-1825
Country	:	US
Telephone Number	:	612-747-1296
Fax Number	:

Provider Business Practice Location Address
First Line	:	1300 S PLEASANT VALLEY RD APT 136
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78741-1825
Country	:	US
Telephone Number	:	612-747-1296
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2024
Last Update Date	:	09/03/2024

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Directions to “ GABRIELLE COOLIDGE ” Practice Location

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