Provider Demographics
NPI:1902548746
Name:SERVICE, GABRIELLA
Entity Type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:
Last Name:SERVICE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 TERRACE RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33896-5249
Mailing Address - Country:US
Mailing Address - Phone:787-239-5921
Mailing Address - Fax:
Practice Address - Street 1:730 SAND LAKE RD STE 176
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-7747
Practice Address - Country:US
Practice Address - Phone:407-942-4461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-209756106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113861500Medicaid