Healthcare Provider Details

I. General information

NPI: 1316440076
Provider Name (Legal Business Name): ANGELICA GAMMAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2018
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9355 E STOCKTON BLVD STE 100
ELK GROVE CA
95624-9476
US

IV. Provider business mailing address

PO BOX 5157
MODESTO CA
95352-5157
US

V. Phone/Fax

Practice location:
  • Phone: 916-683-1109
  • Fax: 916-683-1140
Mailing address:
  • Phone: 209-572-2589
  • Fax: 209-572-1461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number17-46613
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-21-12490
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: