Provider Demographics
NPI:1629719166
Name:ALONSO GAMBOA, ERICK YEOSHUA
Entity Type:Individual
Prefix:
First Name:ERICK
Middle Name:YEOSHUA
Last Name:ALONSO GAMBOA
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 1:6325 N SHERIDAN RD APT 1905
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-5721
Mailing Address - Country:US
Mailing Address - Phone:909-845-9524
Mailing Address - Fax:
Practice Address - Street 1:4433 W TOUHY AVE STE 335
Practice Address - Street 2:
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-1820
Practice Address - Country:US
Practice Address - Phone:877-486-4140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician