Provider Demographics
NPI:1629583125
Name:GAMBERDELLA, MICHELLE ALISE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ALISE
Last Name:GAMBERDELLA
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 1:2351 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BELLBROOK
Mailing Address - State:OH
Mailing Address - Zip Code:45305-1717
Mailing Address - Country:US
Mailing Address - Phone:937-602-2077
Mailing Address - Fax:
Practice Address - Street 1:1785 BIG HILL RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45439-2219
Practice Address - Country:US
Practice Address - Phone:937-264-0084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1701744104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty