Healthcare Provider Details

I. General information

NPI: 1891739876
Provider Name (Legal Business Name): GABRIEL G VALLEJO LPC-S, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PICACHO RD
WINTERHAVEN CA
92283-9605
US

IV. Provider business mailing address

PO BOX 1368
YUMA AZ
85366-2361
US

V. Phone/Fax

Practice location:
  • Phone: 760-572-4712
  • Fax:
Mailing address:
  • Phone: 928-595-1428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-20296
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-20880
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-15087
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-20296
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: