Provider Demographics
NPI:1760756753
Name:SAN ELIAS-GAYTAN, ROSANGEL
Entity Type:Individual
Prefix:
First Name:ROSANGEL
Middle Name:
Last Name:SAN ELIAS-GAYTAN
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 1:12440 FIRESTONE BLVD STE 316
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-9319
Mailing Address - Country:US
Mailing Address - Phone:323-819-2329
Mailing Address - Fax:562-924-1040
Practice Address - Street 1:12440 FIRESTONE BLVD
Practice Address - Street 2:SUITE # 316
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-4328
Practice Address - Country:US
Practice Address - Phone:323-819-2329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-08
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CAASW32737101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker