Provider Demographics
NPI:1629516562
Name:LUTTRULL, GABRIELLE LYN NIEVES
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:LYN NIEVES
Last Name:LUTTRULL
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 1:11722 RAINTREE LAKE LN
Mailing Address - Street 2:#B
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617-9421
Mailing Address - Country:US
Mailing Address - Phone:305-298-0870
Mailing Address - Fax:
Practice Address - Street 1:11722 RAINTREE LAKE LN
Practice Address - Street 2:#B
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617-9421
Practice Address - Country:US
Practice Address - Phone:305-298-0870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health