Provider Demographics
NPI:1639559164
Name:GAULT, JOHN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:GAULT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1939 ROBINSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-3224
Mailing Address - Country:US
Mailing Address - Phone:248-660-6997
Mailing Address - Fax:
Practice Address - Street 1:140 ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2007
Practice Address - Country:US
Practice Address - Phone:619-543-7681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-29
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA912931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical