MEDICARE: AYLIN GISEL GAMBOA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1194421370
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AYLIN GISEL GAMBOA

Provider Business Mailing Address
First Line	:	9516 SHADOW SPRINGS DR
Second Line	:
City	:	MORENO VALLEY
State	:	CA
Zip	:	92557-1822
Country	:	US
Telephone Number	:	951-822-6136
Fax Number	:

Provider Business Practice Location Address
First Line	:	9516 SHADOW SPRINGS DR
Second Line	:
City	:	MORENO VALLEY
State	:	CA
Zip	:	92557-1822
Country	:	US
Telephone Number	:	951-822-6136
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2023
Last Update Date	:	01/31/2023

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