Provider Demographics
NPI:1548903792
Name:OLDFATHER, GABRIELLE
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:OLDFATHER
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 1:5505 HERNANDES DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-4848
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7180 SOUTH KANNER HWY.
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997
Practice Address - Country:US
Practice Address - Phone:772-284-4188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-15
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician