Provider Demographics
NPI:1164662581
Name:DESIERTO, GREGORY GONZAGA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:GONZAGA
Last Name:DESIERTO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 E 12TH ST STE 259
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-2940
Mailing Address - Country:US
Mailing Address - Phone:510-295-7402
Mailing Address - Fax:
Practice Address - Street 1:3301 E 12TH ST STE 259
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2940
Practice Address - Country:US
Practice Address - Phone:510-295-7402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-25
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CAPSY29598103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor