Provider Demographics
NPI:1699976621
Name:PULLEN, GABRIELLE (GCFP, LMT)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:PULLEN
Suffix:
Gender:F
Credentials:GCFP, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 7311
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97530-2854
Mailing Address - Country:US
Mailing Address - Phone:541-777-0124
Mailing Address - Fax:
Practice Address - Street 1:235 W MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97530-9278
Practice Address - Country:US
Practice Address - Phone:541-777-0124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 174400000X, 225400000X
OR25754225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
No172V00000XOther Service ProvidersCommunity Health Worker
No174400000XOther Service ProvidersSpecialist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR25754OtherOREGON STATE BOARD OF MASSAGE THERAPY LICENSE NUMBER