Provider Demographics
NPI:1477078194
Name:NIMTZ, GARY GORDON
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:GORDON
Last Name:NIMTZ
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 1:4575 REVILLO WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-4143
Mailing Address - Country:US
Mailing Address - Phone:619-582-0962
Mailing Address - Fax:
Practice Address - Street 1:1400 N JOHNSON AVE STE 101
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-1651
Practice Address - Country:US
Practice Address - Phone:619-442-0277
Practice Address - Fax:619-442-1101
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-03
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)