MEDICARE: JONATHAN GANDARA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1750903035
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN GANDARA

Provider Business Mailing Address
First Line	:	PO BOX 1851
Second Line	:
City	:	SOUTH GATE
State	:	CA
Zip	:	90280-1851
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3780 KILROY AIRPORT WAY STE 200
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90806-2458
Country	:	US
Telephone Number	:	323-548-8820
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2020
Last Update Date	:	05/10/2020

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Directions to “ JONATHAN GANDARA ” Practice Location

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