=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942652813
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GABRIELLA CARDONA-MORALES PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2016
-----------------------------------------------------
Last Update Date | 07/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 451 CLARKSON AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11203-2054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-734-6113
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 566 DEKALB AVE APT. 3D
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11205-4990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 021674
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------