Healthcare Provider Details

I. General information

NPI: 1477066876
Provider Name (Legal Business Name): ALEXANDRA ROSE GABOURY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2017
Last Update Date: 06/12/2020
Certification Date: 06/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 JUPITER LAKES BLVD STE 5101
JUPITER FL
33458-7183
US

IV. Provider business mailing address

868 SW HIDDEN RIVER AVE
PALM CITY FL
34990-2004
US

V. Phone/Fax

Practice location:
  • Phone: 561-741-1876
  • Fax: 888-721-1997
Mailing address:
  • Phone: 443-852-3453
  • Fax: 888-721-1997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number27863
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: