Provider Demographics
NPI:1356483325
Name:CASILLAS, GABRIEL A
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:A
Last Name:CASILLAS
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 1:4460 CARMEN ST
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-3970
Mailing Address - Country:US
Mailing Address - Phone:626-290-3167
Mailing Address - Fax:
Practice Address - Street 1:1517 W GARVEY AVE N
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2138
Practice Address - Country:US
Practice Address - Phone:626-962-6061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT30357167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician