Provider Demographics
NPI:1639794464
Name:CANTU, GABRIEL EZEQUIEL
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:EZEQUIEL
Last Name:CANTU
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 1:4026 CANDLE PARK
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78410
Mailing Address - Country:US
Mailing Address - Phone:361-945-8662
Mailing Address - Fax:
Practice Address - Street 1:21727 I-10
Practice Address - Street 2:UNIT 108
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78257
Practice Address - Country:US
Practice Address - Phone:210-455-1091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-20-2858205401106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician