Provider Demographics
NPI:1578685194
Name:SALAS, GABRIEL
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:SALAS
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 1:924 INVERNESS AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-5356
Mailing Address - Country:US
Mailing Address - Phone:626-255-4216
Mailing Address - Fax:
Practice Address - Street 1:4401 SANTA ANITA AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-1611
Practice Address - Country:US
Practice Address - Phone:626-246-1767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 225400000X
CA62612106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner