Provider Demographics
NPI:1093297392
Name:CONTRERAS, GILBERTO
Entity Type:Individual
Prefix:
First Name:GILBERTO
Middle Name:
Last Name:CONTRERAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 E GREENLAW LN STE 10B
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1849
Mailing Address - Country:US
Mailing Address - Phone:928-226-1097
Mailing Address - Fax:
Practice Address - Street 1:9146 W SLATE MOUNTAIN TRAIL
Practice Address - Street 2:
Practice Address - City:BELLEMONT
Practice Address - State:AZ
Practice Address - Zip Code:86015
Practice Address - Country:US
Practice Address - Phone:928-607-3598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-04
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
385HR2055X
AZ9314517253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child