Provider Demographics
NPI:1558957167
Name:CABALLERO, GRETEL
Entity Type:Individual
Prefix:
First Name:GRETEL
Middle Name:
Last Name:CABALLERO
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 1:5504 EIGHT BELLS LN APT 104
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-1077
Mailing Address - Country:US
Mailing Address - Phone:502-419-6705
Mailing Address - Fax:
Practice Address - Street 1:2301 ROCKFORD LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-2948
Practice Address - Country:US
Practice Address - Phone:502-419-6705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-17
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY304211OtherATHLETIC TRAINING STUDENT