Provider Demographics
NPI:1710601794
Name:ACOSTA, GISELLE
Entity Type:Individual
Prefix:
First Name:GISELLE
Middle Name:
Last Name:ACOSTA
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 1:249 E TABERNACLE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-2951
Mailing Address - Country:US
Mailing Address - Phone:435-705-7574
Mailing Address - Fax:
Practice Address - Street 1:249 E TABERNACLE ST STE 100
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-2951
Practice Address - Country:US
Practice Address - Phone:435-705-7574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician