Healthcare Provider Details

I. General information

NPI: 1225335722
Provider Name (Legal Business Name): GAETANO VACCARO PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2011
Last Update Date: 09/11/2025
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33749 SKY BLUE WATER TRL
CATHEDRAL CITY CA
92234-4453
US

IV. Provider business mailing address

PO BOX 2332
CATHEDRAL CITY CA
92235-2332
US

V. Phone/Fax

Practice location:
  • Phone: 323-806-3227
  • Fax:
Mailing address:
  • Phone: 323-806-3227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPSY26314
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: