MEDICARE: GABRIELLE PATRICIA RUSSO

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		GA

General Provider Information

NPI Number	:	1922930908
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIELLE PATRICIA RUSSO

Provider Business Mailing Address
First Line	:	300 INTERNATIONAL PKWY STE 200
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-5028
Country	:	US
Telephone Number	:	866-610-0580
Fax Number	:	866-611-1558

Provider Business Practice Location Address
First Line	:	1664 MARKET PLACE BLVD
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30041-7927
Country	:	US
Telephone Number	:	470-253-4121
Fax Number	:

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

Provider Enumeration Date	:	06/02/2026
Last Update Date	:	06/02/2026

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