Provider Demographics
NPI:1376722280
Name:QUAN, GARY
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:QUAN
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 1:411 NORTHLAKE DR APT 5
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95117-1381
Mailing Address - Country:US
Mailing Address - Phone:408-931-1111
Mailing Address - Fax:
Practice Address - Street 1:707 FAIR AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-5828
Practice Address - Country:US
Practice Address - Phone:831-427-1007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)