Provider Demographics
NPI:1003636226
Name:MEDINA, GABRIELLE (MA)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 S CEDAR ST APT 31
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-3463
Mailing Address - Country:US
Mailing Address - Phone:970-821-6468
Mailing Address - Fax:
Practice Address - Street 1:925 S BROADWAY STE 211
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-4033
Practice Address - Country:US
Practice Address - Phone:970-516-7049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0022446101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health