Provider Demographics
NPI:1073103743
Name:GAMBREALL, VERONICA AURELIA (224Z00000X)
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:AURELIA
Last Name:GAMBREALL
Suffix:
Gender:F
Credentials:224Z00000X
Other - Prefix:
Other - First Name:VERONICA
Other - Middle Name:AURELIA
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:224Z00000X
Mailing Address - Street 1:104 HARRIS PL
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:SC
Mailing Address - Zip Code:29670-1826
Mailing Address - Country:US
Mailing Address - Phone:864-324-2205
Mailing Address - Fax:
Practice Address - Street 1:1501 E GREENVILLE ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-2004
Practice Address - Country:US
Practice Address - Phone:864-226-8356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2485224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant