Healthcare Provider Details

I. General information

NPI: 1871164400
Provider Name (Legal Business Name): GABRIELLE ANDREA DIZON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2021
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1214 NATIONAL AVE
LAS VEGAS NM
87701-4033
US

IV. Provider business mailing address

132 KIRK RD
HAMDEN CT
06514-1310
US

V. Phone/Fax

Practice location:
  • Phone: 505-426-8095
  • Fax:
Mailing address:
  • Phone: 203-606-6118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: