Healthcare Provider Details

I. General information

NPI: 1194386516
Provider Name (Legal Business Name): GABRIELLE J MORENO BS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 HEALTH SERVICES DR
DEKALB IL
60115-9637
US

IV. Provider business mailing address

14 HEALTH SERVICES DR
DEKALB IL
60115-9637
US

V. Phone/Fax

Practice location:
  • Phone: 815-758-8616
  • Fax:
Mailing address:
  • Phone: 815-758-8616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: