Provider Demographics
NPI:1497383087
Name:BOU, GABRIELA ALEJANDRA
Entity Type:Individual
Prefix:
First Name:GABRIELA
Middle Name:ALEJANDRA
Last Name:BOU
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 1:652 ANGIER AVE NE APT 602
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-3190
Mailing Address - Country:US
Mailing Address - Phone:813-495-2357
Mailing Address - Fax:
Practice Address - Street 1:12 EXECUTIVE PARK DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2206
Practice Address - Country:US
Practice Address - Phone:404-778-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA125302084N0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology