Provider Demographics
NPI:1497125637
Name:GASTELUM, ANTHONY
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:GASTELUM
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:PO BOX 589
Mailing Address - Street 2:
Mailing Address - City:KAKE
Mailing Address - State:AK
Mailing Address - Zip Code:99830-0589
Mailing Address - Country:US
Mailing Address - Phone:907-785-6515
Mailing Address - Fax:907-785-3350
Practice Address - Street 1:101 TOTEM ST.
Practice Address - Street 2:KAKE CLINIC
Practice Address - City:KAKE
Practice Address - State:AK
Practice Address - Zip Code:99830
Practice Address - Country:US
Practice Address - Phone:907-785-6515
Practice Address - Fax:907-785-3350
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
AK101YA0400X101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor