Healthcare Provider Details

I. General information

NPI: 1942333489
Provider Name (Legal Business Name): GREGORIO J CANILLAS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 E COLORADO BLVD SUITE 100-101
PASADENA CA
91107-6622
US

IV. Provider business mailing address

1175 E OCEAN BLVD UNIT 211
LONG BEACH CA
90802-5674
US

V. Phone/Fax

Practice location:
  • Phone: 626-577-2261
  • Fax: 626-577-2543
Mailing address:
  • Phone: 562-951-5643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: