Provider Demographics
NPI:1467175067
Name:EDRICH, GABRIELLE
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:EDRICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8731 SERENE RETREAT LN APT 312
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-7350
Mailing Address - Country:US
Mailing Address - Phone:954-850-7740
Mailing Address - Fax:
Practice Address - Street 1:602 VONDERBURG DR STE 201
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5900
Practice Address - Country:US
Practice Address - Phone:813-653-1149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ11006390200000X
FL22028235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program