Provider Demographics
NPI:1114237948
Name:CORDERO, GISSELLE
Entity type:Individual
Prefix:
First Name:GISSELLE
Middle Name:
Last Name:CORDERO
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 1:17400 SW 267TH LN
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33031-2336
Mailing Address - Country:US
Mailing Address - Phone:305-910-5057
Mailing Address - Fax:
Practice Address - Street 1:17400 SW 267TH LN
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33031-2336
Practice Address - Country:US
Practice Address - Phone:305-910-5057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13010101YM0800X
1-19-35552103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health