Provider Demographics
NPI:1790452472
Name:MOFFITT, GABRIELLA NICOLE
Entity Type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:NICOLE
Last Name:MOFFITT
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 1:208 N WALTON BLVD STE 9
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-5080
Mailing Address - Country:US
Mailing Address - Phone:479-544-0166
Mailing Address - Fax:
Practice Address - Street 1:208 N WALTON BLVD STE 9
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-5080
Practice Address - Country:US
Practice Address - Phone:479-544-0166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician