Provider Demographics
NPI:1558814988
Name:MORTELLARO, GABRIELLE
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:MORTELLARO
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 1:8092 W PARADISE LN
Mailing Address - Street 2:APT 2116
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-4976
Mailing Address - Country:US
Mailing Address - Phone:928-308-3402
Mailing Address - Fax:
Practice Address - Street 1:8092 W PARADISE LN
Practice Address - Street 2:APT 2116
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-4976
Practice Address - Country:US
Practice Address - Phone:928-308-3402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA100992355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant