Healthcare Provider Details

I. General information

NPI: 1487004149
Provider Name (Legal Business Name): STEVEN GASTELUM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2178 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4535
US

IV. Provider business mailing address

8595 SAN ANDRES AVE.
ATASCADERO CA
93422
US

V. Phone/Fax

Practice location:
  • Phone: 805-781-4712
  • Fax: 805-781-4145
Mailing address:
  • Phone: 805-462-2809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT 30628
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: