Provider Demographics
NPI:1164638458
Name:BURLESON, GABRIELLA
Entity Type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:
Last Name:BURLESON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GABRIELLA
Other - Middle Name:
Other - Last Name:DEGALDO BURLESON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1120 S DORA ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-6340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1120 S DORA ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-6340
Practice Address - Country:US
Practice Address - Phone:707-472-2719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered171M00000XOther Service ProvidersCase Manager/Care Coordinator
Not Answered171R00000XOther Service ProvidersInterpreter