Provider Demographics
NPI:1376900340
Name:GANDARA, CRISTIAN
Entity Type:Individual
Prefix:
First Name:CRISTIAN
Middle Name:
Last Name:GANDARA
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 1:9625 LOCHINVAR DR
Mailing Address - Street 2:
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-3935
Mailing Address - Country:US
Mailing Address - Phone:323-828-9551
Mailing Address - Fax:323-978-6035
Practice Address - Street 1:9625 LOCHINVAR DR
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660
Practice Address - Country:US
Practice Address - Phone:323-828-9551
Practice Address - Fax:323-978-6035
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-21
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-15-20678103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst