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General NPI Number Information
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NPI Number | 1841013885
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Entity Type | Individual
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Provider Name | KENNETH JONAVIL P GAMBOA
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Gender | Female
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Dates
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Enumeration Date | 11/07/2024
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Last Update Date | 11/07/2024
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Provider Practice Location Address
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Address Line | 7110 STEIGER HILL RD
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City | VACAVILLE
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State | CA
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Zip | 95688-9789
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Country | US
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Telephone | 707-656-6625
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Fax |
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Provider Business Mailing Address
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Address Line | 1806 WOOD DUCK CT
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City | AMERICAN CANYON
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State | CA
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Zip | 94503-3125
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | 21-155551
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 167G00000X
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Taxonomy Name | Licensed Psychiatric Technician
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License Number | 40215
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License Number State | CA
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