Provider Demographics
NPI:1164554838
Name:GAMBOA, YANET R
Entity Type:Individual
Prefix:
First Name:YANET
Middle Name:R
Last Name:GAMBOA
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 1:10871 DATE ST
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:CA
Mailing Address - Zip Code:90680-3018
Mailing Address - Country:US
Mailing Address - Phone:714-785-4638
Mailing Address - Fax:
Practice Address - Street 1:21520 PIONEER BLVD STE 110
Practice Address - Street 2:
Practice Address - City:HAWAIIAN GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90716-2603
Practice Address - Country:US
Practice Address - Phone:562-865-3644
Practice Address - Fax:562-246-5704
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49428106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist