Healthcare Provider Details

I. General information

NPI: 1528791639
Provider Name (Legal Business Name): GABRIELLA GAMBOA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GABRIELLA GUTIERREZ

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 MAIN ST
MELROSE PARK IL
60160-3902
US

IV. Provider business mailing address

5411 S KENNETH AVE
CHICAGO IL
60632-4725
US

V. Phone/Fax

Practice location:
  • Phone: 708-681-0073
  • Fax: 708-681-3958
Mailing address:
  • Phone: 872-769-5028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: