Provider Demographics
NPI:1326893041
Name:PRINCE-GAMBOA, ALLEN ERSKINE
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:ERSKINE
Last Name:PRINCE-GAMBOA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3207 LAKE TWYLO RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817
Mailing Address - Country:US
Mailing Address - Phone:321-367-6032
Mailing Address - Fax:
Practice Address - Street 1:3207 LAKE TWYLO RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817
Practice Address - Country:US
Practice Address - Phone:321-367-6032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician