Provider Demographics
NPI:1215305503
Name:KOSSARIS, GABRIELLE
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:KOSSARIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GABRIELLE
Other - Middle Name:
Other - Last Name:LARREA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-974-2201
Mailing Address - Fax:813-974-4325
Practice Address - Street 1:4202 E FOWLER AVE
Practice Address - Street 2:PCD1017
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33620-6750
Practice Address - Country:US
Practice Address - Phone:813-974-9844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-03
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA14641235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015654100Medicaid
FLQ41O2OtherBLUE CROSS BLUE SHIELD
FL015654100Medicaid