1528743408 NPI number — MISS GABRIELLE MARILYN PEREBOOM TLMHC

Table of content: MISS GABRIELLE MARILYN PEREBOOM TLMHC (NPI 1528743408)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528743408 NPI number — MISS GABRIELLE MARILYN PEREBOOM TLMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEREBOOM
Provider First Name:
GABRIELLE
Provider Middle Name:
MARILYN
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
TLMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PEREBOOM
Provider Other First Name:
ELLIE
Provider Other Middle Name:
MARILYN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1528743408
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1630 42ND ST NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDAR RAPIDS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52402-3063
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-531-4236
Provider Business Mailing Address Fax Number:
319-483-6661

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1630 42ND ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CEDAR RAPIDS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52402-3063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-531-4236
Provider Business Practice Location Address Fax Number:
319-483-6661
Provider Enumeration Date:
06/19/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  120642 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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