MEDICARE: GABRIELLE CORICE BOSTICK LMFTA

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	106H00000X	Marriage & Family Therapist	10129A	NC

General Provider Information

NPI Number	:	1508745290
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIELLE CORICE BOSTICK LMFTA

Provider Business Mailing Address
First Line	:	5020 RIDGE RD UNIT 4108
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-0256
Country	:	US
Telephone Number	:	843-260-2863
Fax Number	:

Provider Business Practice Location Address
First Line	:	8535 CLIFF CAMERON DR STE 100
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-5909
Country	:	US
Telephone Number	:	704-717-7477
Fax Number	:	704-717-7457

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

Provider Enumeration Date	:	08/28/2025
Last Update Date	:	12/12/2025

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