Provider Demographics
NPI:1518556521
Name:TALAMANTES, GABRIELLA
Entity Type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:
Last Name:TALAMANTES
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 1:5 REVERE DR STE 120
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-8005
Mailing Address - Country:US
Mailing Address - Phone:858-428-0222
Mailing Address - Fax:847-348-3706
Practice Address - Street 1:9245 ACTIVITY RD STE 106
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4442
Practice Address - Country:US
Practice Address - Phone:858-428-0222
Practice Address - Fax:847-348-3706
Is Sole Proprietor?:No
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-21-151042106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician