Provider Demographics
NPI:1477159184
Name:BOTELLO, GABRIELA
Entity Type:Individual
Prefix:
First Name:GABRIELA
Middle Name:
Last Name:BOTELLO
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 1:6051 N FRESNO ST STE 102
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5280
Mailing Address - Country:US
Mailing Address - Phone:559-650-7224
Mailing Address - Fax:
Practice Address - Street 1:6051 N FRESNO ST STE 102
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5280
Practice Address - Country:US
Practice Address - Phone:559-650-7224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-23-65576103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05291997OtherDOB