Provider Demographics
NPI:1720247463
Name:THEVENIN, GISELLE ALEJANDRA (COTA/L)
Entity type:Individual
Prefix:MISS
First Name:GISELLE
Middle Name:ALEJANDRA
Last Name:THEVENIN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19499 NE 10TH AVE
Mailing Address - Street 2:APT 304
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33179-5732
Mailing Address - Country:US
Mailing Address - Phone:786-262-3729
Mailing Address - Fax:
Practice Address - Street 1:2040 NE 163RD ST
Practice Address - Street 2:SUITE 306
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-4951
Practice Address - Country:US
Practice Address - Phone:786-306-9562
Practice Address - Fax:954-966-6412
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-06
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10684172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker