Basic Information
| Provider Information | |||||||||
| NPI: | 1952829715 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAILEY | ||||||||
| FirstName: | GABRIELLE | ||||||||
| MiddleName: | B | ||||||||
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| Mailing Information | |||||||||
| Address1: | 715 TERRACE ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494401107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318309376 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3391 MERRIAM ST | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494443155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318309376 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2017 | ||||||||
| LastUpdateDate: | 08/31/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 94708763301 | 01 | MI | PRIORITY HEALTH | OTHER |