Healthcare Provider Details

I. General information

NPI: 1366110538
Provider Name (Legal Business Name): MR. GABRIEL SANTOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2021
Last Update Date: 09/18/2021
Certification Date: 09/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18152 LULL ST
RESEDA CA
91335-2048
US

IV. Provider business mailing address

18152 LULL ST
RESEDA CA
91335-2048
US

V. Phone/Fax

Practice location:
  • Phone: 510-314-6423
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: