Provider Demographics
NPI:1447766894
Name:WUTTKE, GABRIELLE MEGAN (RBT)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:MEGAN
Last Name:WUTTKE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2145 NE 164TH ST APT 824
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-4298
Mailing Address - Country:US
Mailing Address - Phone:305-321-5008
Mailing Address - Fax:
Practice Address - Street 1:2145 NE 164TH ST APT 824
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162
Practice Address - Country:US
Practice Address - Phone:305-321-5008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-21
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-16-20551106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician