Provider Demographics
NPI:1457997207
Name:BALANCIER, GABRIELLE CHANELL
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:CHANELL
Last Name:BALANCIER
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 1:13375 ARBOR POINTE CIR APT 101
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617-1141
Mailing Address - Country:US
Mailing Address - Phone:985-788-4502
Mailing Address - Fax:
Practice Address - Street 1:10909 MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-2511
Practice Address - Country:US
Practice Address - Phone:985-788-4502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH18910101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health