Healthcare Provider Details

I. General information

NPI: 1093375552
Provider Name (Legal Business Name): GABRIELLA TASSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 06/06/2026
Certification Date: 06/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 DOCTORS DR STE J
JACKSONVILLE NC
28546-6308
US

IV. Provider business mailing address

9375 E SHEA BLVD
SCOTTSDALE AZ
85260-6991
US

V. Phone/Fax

Practice location:
  • Phone: 404-400-5004
  • Fax:
Mailing address:
  • Phone: 404-400-5004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-49951
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: