Provider Demographics
NPI:1871030221
Name:YZAGUIRRE, GARY ALAN
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ALAN
Last Name:YZAGUIRRE
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 1:243 E 48TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-1213
Mailing Address - Country:US
Mailing Address - Phone:909-582-5234
Mailing Address - Fax:
Practice Address - Street 1:15770 MOJAVE DR
Practice Address - Street 2:SUITE L
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394-1934
Practice Address - Country:US
Practice Address - Phone:760-843-7809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA168530101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)