Provider Demographics
NPI:1558008128
Name:NOVELLA, GABRIELLE URUENA
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:URUENA
Last Name:NOVELLA
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:PO BOX 3676
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91729-3676
Mailing Address - Country:US
Mailing Address - Phone:909-660-3027
Mailing Address - Fax:
Practice Address - Street 1:17057 FOOTHILL BLVD STE 205
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3523
Practice Address - Country:US
Practice Address - Phone:909-660-3027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT120146106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000OtherINSURANCE PROVIDER