MEDICARE: GABRIELLA NICOLE MOFFITT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1790452472
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIELLA NICOLE MOFFITT

Provider Business Mailing Address
First Line	:	208 N WALTON BLVD STE 9
Second Line	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72712-5080
Country	:	US
Telephone Number	:	479-544-0166
Fax Number	:

Provider Business Practice Location Address
First Line	:	208 N WALTON BLVD STE 9
Second Line	:
City	:	BENTONVILLE
State	:	AR
Zip	:	72712-5080
Country	:	US
Telephone Number	:	479-544-0166
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2021
Last Update Date	:	08/30/2021

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