Healthcare Provider Details

I. General information

NPI: 1699899674
Provider Name (Legal Business Name): OMAR GABRIEL GUDINO PH.D., ABPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 ALAMEDA DE LAS PULGAS STE 242
SAN MATEO CA
94403-1271
US

IV. Provider business mailing address

2000 ALAMEDA DE LAS PULGAS STE 242
SAN MATEO CA
94403-1271
US

V. Phone/Fax

Practice location:
  • Phone: 650-931-6565
  • Fax:
Mailing address:
  • Phone: 650-931-6565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number34415
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number018596
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number018596
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number34415
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: