Provider Demographics
NPI:1619183761
Name:GAYNOR, AILEEN KATHLEEN
Entity Type:Individual
Prefix:
First Name:AILEEN
Middle Name:KATHLEEN
Last Name:GAYNOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 B SOUTH LENORE ST.
Mailing Address - Street 2:
Mailing Address - City:WILLITS
Mailing Address - State:CA
Mailing Address - Zip Code:95490
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 S LENORE AVE # B
Practice Address - Street 2:
Practice Address - City:WILLITS
Practice Address - State:CA
Practice Address - Zip Code:95490-3632
Practice Address - Country:US
Practice Address - Phone:707-456-3820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACATC# 061326101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)