Provider Demographics
NPI:1215645510
Name:GO, GABRIELLE LIANN (DPT)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:LIANN
Last Name:GO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14310 AUTUMN GOLD RD
Mailing Address - Street 2:
Mailing Address - City:BOYDS
Mailing Address - State:MD
Mailing Address - Zip Code:20841-4209
Mailing Address - Country:US
Mailing Address - Phone:240-308-2285
Mailing Address - Fax:
Practice Address - Street 1:14310 AUTUMN GOLD RD
Practice Address - Street 2:
Practice Address - City:BOYDS
Practice Address - State:MD
Practice Address - Zip Code:20841-4209
Practice Address - Country:US
Practice Address - Phone:240-308-2285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD292222081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine