Provider Demographics
NPI:1164962585
Name:LOFTON, GABRIELLA ELENORA
Entity Type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:ELENORA
Last Name:LOFTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GABRIELLA
Other - Middle Name:ELENORA
Other - Last Name:SEIDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4225 SOUTHPORT CIR APT 3C
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-2807
Mailing Address - Country:US
Mailing Address - Phone:517-230-4915
Mailing Address - Fax:
Practice Address - Street 1:9080 W MAPLE RAPIDS RD
Practice Address - Street 2:
Practice Address - City:FOWLER
Practice Address - State:MI
Practice Address - Zip Code:48835-9605
Practice Address - Country:US
Practice Address - Phone:517-230-4915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-03
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIS 300 271 205 932106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician