Provider Demographics
NPI:1134692023
Name:GASTON, DANITA
Entity Type:Individual
Prefix:
First Name:DANITA
Middle Name:
Last Name:GASTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1432 STUYVESANT AVE
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08618-3308
Mailing Address - Country:US
Mailing Address - Phone:609-968-7054
Mailing Address - Fax:
Practice Address - Street 1:1432 STUYVESANT AVE
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08618-3308
Practice Address - Country:US
Practice Address - Phone:609-968-7054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0021997Medicaid