Provider Demographics
NPI:1548837958
Name:GAMBRELL, TINA MARIE
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:GAMBRELL
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 1:2751 NAPA VALLEY CORPORATE DR # A211
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-6216
Mailing Address - Country:US
Mailing Address - Phone:707-253-4326
Mailing Address - Fax:707-299-2165
Practice Address - Street 1:2751 NAPA VALLEY CORPORATE DR BLDG A
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-6216
Practice Address - Country:US
Practice Address - Phone:707-299-1760
Practice Address - Fax:707-299-2199
Is Sole Proprietor?:No
Enumeration Date:2021-06-06
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CA109776104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YM0800XMedicaid