Provider Demographics
NPI:1184479065
Name:BODOW, GABRIELLE WEINBERG (PHD)
Entity type:Individual
Prefix:DR
First Name:GABRIELLE
Middle Name:WEINBERG
Last Name:BODOW
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1137 2ND STREET #207
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403
Mailing Address - Country:US
Mailing Address - Phone:310-860-9040
Mailing Address - Fax:
Practice Address - Street 1:1137 2ND STREET #207
Practice Address - Street 2:SUITE 207
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403
Practice Address - Country:US
Practice Address - Phone:310-860-9040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13060103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty