Provider Demographics
NPI:1821878059
Name:KNOBLOCH, GAVIN (CADC I CI37960323)
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:
Last Name:KNOBLOCH
Suffix:
Gender:M
Credentials:CADC I CI37960323
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5754 W ELLERY AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-3144
Mailing Address - Country:US
Mailing Address - Phone:559-645-2882
Mailing Address - Fax:
Practice Address - Street 1:351 MALL DR
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-5950
Practice Address - Country:US
Practice Address - Phone:559-978-0998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACI37960323101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)