Provider Demographics
NPI:1285063248
Name:GABRIELSON, THEADORA
Entity type:Individual
Prefix:
First Name:THEADORA
Middle Name:
Last Name:GABRIELSON
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 1:2688 ASHFORD RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319-3260
Mailing Address - Country:US
Mailing Address - Phone:770-366-0066
Mailing Address - Fax:770-216-1947
Practice Address - Street 1:1640 POWERS FERRY RD SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-5491
Practice Address - Country:US
Practice Address - Phone:770-366-0066
Practice Address - Fax:770-988-9296
Is Sole Proprietor?:No
Enumeration Date:2013-11-10
Last Update Date:2013-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAMFT 000279106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAAMFT 000279OtherLICENSE NUMBER