Provider Demographics
NPI:1255349106
Name:BUETTOW, GABRIELLE ANN (LCSW)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:ANN
Last Name:BUETTOW
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:GABRIELLE
Other - Middle Name:ANN
Other - Last Name:COSTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1201 1ST ST S
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3904
Mailing Address - Country:US
Mailing Address - Phone:863-294-7062
Mailing Address - Fax:
Practice Address - Street 1:1201 1ST ST S
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3904
Practice Address - Country:US
Practice Address - Phone:863-293-1121
Practice Address - Fax:863-291-6084
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW7287104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL765796000Medicaid