Provider Demographics
NPI:1558031104
Name:THALIN, GABRIELLA (OTR/L)
Entity Type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:
Last Name:THALIN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:GABRIELLA
Other - Middle Name:
Other - Last Name:THALIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2695 N WOLVERINE AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-3484
Mailing Address - Country:US
Mailing Address - Phone:310-686-4402
Mailing Address - Fax:
Practice Address - Street 1:2273 E GALA ST STE 120
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7289
Practice Address - Country:US
Practice Address - Phone:208-323-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2423225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist