Provider Demographics
NPI:1447035712
Name:DWIDJAYA, GABRIELLA MARIA AMADEA
Entity type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:MARIA AMADEA
Last Name:DWIDJAYA
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 1:26322 165TH PL SE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98042-5830
Mailing Address - Country:US
Mailing Address - Phone:253-329-0008
Mailing Address - Fax:
Practice Address - Street 1:2018 156TH AVE NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-3825
Practice Address - Country:US
Practice Address - Phone:971-358-9812
Practice Address - Fax:206-299-7030
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2023-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician