Provider Demographics
NPI:1124562913
Name:GASCON, VENANCIO MICHAEL
Entity Type:Individual
Prefix:
First Name:VENANCIO
Middle Name:MICHAEL
Last Name:GASCON
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 1:5928 BELLINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94552-1625
Mailing Address - Country:US
Mailing Address - Phone:510-305-3088
Mailing Address - Fax:
Practice Address - Street 1:424 PENINSULA AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-1653
Practice Address - Country:US
Practice Address - Phone:650-286-4396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD7151869103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst