Provider Demographics
NPI:1609006287
Name:GONTANG, AUSTIN JOSEPH (PHD)
Entity Type:Individual
Prefix:DR
First Name:AUSTIN
Middle Name:JOSEPH
Last Name:GONTANG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:OZZIE
Other - Middle Name:
Other - Last Name:GONTANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2903 29TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-4912
Mailing Address - Country:US
Mailing Address - Phone:619-281-7447
Mailing Address - Fax:619-281-9468
Practice Address - Street 1:2903 29TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-4912
Practice Address - Country:US
Practice Address - Phone:619-281-7447
Practice Address - Fax:619-281-9468
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 7695106H00000X
CA7695106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist