Provider Demographics
NPI:1215346341
Name:CLEMENTE, GABRIELA
Entity type:Individual
Prefix:
First Name:GABRIELA
Middle Name:
Last Name:CLEMENTE
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 1:1180 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:KING CITY
Mailing Address - State:CA
Mailing Address - Zip Code:93930-3602
Mailing Address - Country:US
Mailing Address - Phone:831-386-9340
Mailing Address - Fax:
Practice Address - Street 1:1180 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:KING CITY
Practice Address - State:CA
Practice Address - Zip Code:93930-3602
Practice Address - Country:US
Practice Address - Phone:831-386-9340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-02
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA68222101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker