Provider Demographics
NPI:1366500423
Name:GAVRIEL, MARDELL JODY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARDELL
Middle Name:JODY
Last Name:GAVRIEL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 MISSION ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-2417
Mailing Address - Country:US
Mailing Address - Phone:415-967-7042
Mailing Address - Fax:
Practice Address - Street 1:1735 MISSION ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-2417
Practice Address - Country:US
Practice Address - Phone:415-967-7042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16532103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical