Provider Demographics
NPI:1053069872
Name:FONTENOT, GABRIELLE (RBT)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1161 LAKE COOK RD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-5649
Mailing Address - Country:US
Mailing Address - Phone:224-284-2240
Mailing Address - Fax:312-893-2118
Practice Address - Street 1:1161 LAKE COOK RD
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-5649
Practice Address - Country:US
Practice Address - Phone:224-284-2240
Practice Address - Fax:312-893-2118
Is Sole Proprietor?:No
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-22-206735106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician