Provider Demographics
NPI:1578202073
Name:CANALS, GUSTAVO ALEJANDRO (MA, ATC)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:ALEJANDRO
Last Name:CANALS
Suffix:
Gender:M
Credentials:MA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13104 TALL SHADOWS LN APT A
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-5004
Mailing Address - Country:US
Mailing Address - Phone:571-215-1880
Mailing Address - Fax:
Practice Address - Street 1:13104 TALL SHADOWS LN APT A
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-5004
Practice Address - Country:US
Practice Address - Phone:571-215-1880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer