Provider Demographics
NPI:1972138139
Name:GAMBINO, JOELLE (BCBA)
Entity type:Individual
Prefix:
First Name:JOELLE
Middle Name:
Last Name:GAMBINO
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5708 MONMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:VENTNOR CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08406-1844
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:407 GLENN AVE
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-6109
Practice Address - Country:US
Practice Address - Phone:609-214-8664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJBACB365366103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3316Medicaid