Provider Demographics
NPI:1528193117
Name:SANCHEZ, GUSTAVO AVILA
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:AVILA
Last Name:SANCHEZ
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 939
Mailing Address - Street 2:
Mailing Address - City:ANGELS CAMP
Mailing Address - State:CA
Mailing Address - Zip Code:95222-0939
Mailing Address - Country:US
Mailing Address - Phone:209-754-6262
Mailing Address - Fax:209-736-1814
Practice Address - Street 1:5192 HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95388
Practice Address - Country:US
Practice Address - Phone:209-742-6144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT43602106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist