Provider Demographics
NPI:1316587702
Name:MANDUJANO, GABRIELA
Entity type:Individual
Prefix:
First Name:GABRIELA
Middle Name:
Last Name:MANDUJANO
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 1:4801 FRANKFORD RD STE 300
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-5329
Mailing Address - Country:US
Mailing Address - Phone:214-390-3259
Mailing Address - Fax:214-390-3259
Practice Address - Street 1:4801 FRANKFORD RD STE 300
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75287-5329
Practice Address - Country:US
Practice Address - Phone:214-390-3259
Practice Address - Fax:214-390-3259
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-13
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75817101YP2500X
TX202878106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional