Provider Demographics
NPI:1902642242
Name:GARDON MENA, GABRIELA DE LA CARIDAD
Entity type:Individual
Prefix:
First Name:GABRIELA
Middle Name:DE LA CARIDAD
Last Name:GARDON MENA
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 1:3853 NORTHDALE BLVD STE 155
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1861
Mailing Address - Country:US
Mailing Address - Phone:813-418-9038
Mailing Address - Fax:
Practice Address - Street 1:4821 PRESIDENTIAL ST
Practice Address - Street 2:
Practice Address - City:SEFFNER
Practice Address - State:FL
Practice Address - Zip Code:33584-8303
Practice Address - Country:US
Practice Address - Phone:786-381-7081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-05
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB1037582106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty