Provider Demographics
NPI:1497128706
Name:CAMPUZANO, GISELLE
Entity Type:Individual
Prefix:
First Name:GISELLE
Middle Name:
Last Name:CAMPUZANO
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 1:305 EAST DR
Mailing Address - Street 2:SUITE L
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1033
Mailing Address - Country:US
Mailing Address - Phone:321-345-0861
Mailing Address - Fax:321-765-6434
Practice Address - Street 1:305 EAST DR
Practice Address - Street 2:SUITE L
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1033
Practice Address - Country:US
Practice Address - Phone:321-345-0861
Practice Address - Fax:321-765-6434
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-15-01273103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CORBT-15-01273OtherRBT