=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902548746
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GABRIELLA SERVICE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2022
-----------------------------------------------------
Last Update Date | 04/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 730 SAND LAKE RD STE 176
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32809-7747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-942-4461
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 123 TERRACE RIDGE CIR
-----------------------------------------------------
City | DAVENPORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33896-5249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-239-5921
-----------------------------------------------------
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 | RBT-22-209756
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------