=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699516211
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHELSEA GABRISH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2024
-----------------------------------------------------
Last Update Date | 06/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1070 W HOUGHTON LAKE DR
-----------------------------------------------------
City | PRUDENVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48651-9613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-387-4617
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 281
-----------------------------------------------------
City | BARRYTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49305-0281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-429-7259
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------