Healthcare Provider Details

I. General information

NPI: 1982269932
Provider Name (Legal Business Name): ELIZABETH GASTELUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2019
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5190 ATLANTIC AVE
LONG BEACH CA
90805-6510
US

IV. Provider business mailing address

5190 ATLANTIC AVE
LONG BEACH CA
90805-6510
US

V. Phone/Fax

Practice location:
  • Phone: 562-428-4111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2213099
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: