Healthcare Provider Details

I. General information

NPI: 1669172433
Provider Name (Legal Business Name): GISELLE CHACON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2023
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11799 SEBASTIAN WAY STE 103
RANCHO CUCAMONGA CA
91730-0708
US

IV. Provider business mailing address

3600 LIME ST STE 612
RIVERSIDE CA
92501-0919
US

V. Phone/Fax

Practice location:
  • Phone: 909-353-7547
  • Fax:
Mailing address:
  • Phone: 951-357-6926
  • Fax: 951-813-4034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT2536731100660
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: