Provider Demographics
NPI:1134425465
Name:IBANEZ, GISELLE
Entity type:Individual
Prefix:
First Name:GISELLE
Middle Name:
Last Name:IBANEZ
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 1:1630 NW 18TH ST APT 6
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-2442
Mailing Address - Country:US
Mailing Address - Phone:786-399-0357
Mailing Address - Fax:
Practice Address - Street 1:1630 NW 18 ST APTO 6
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125
Practice Address - Country:US
Practice Address - Phone:786-399-0357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-03
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA61606225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist