Provider Demographics
NPI:1740007616
Name:GAYTAN, XIOMARA
Entity type:Individual
Prefix:
First Name:XIOMARA
Middle Name:
Last Name: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 1:2043 SAN FRANCISCO AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-4146
Mailing Address - Country:US
Mailing Address - Phone:760-998-6352
Mailing Address - Fax:
Practice Address - Street 1:2761 SATURN ST
Practice Address - Street 2:SUITE J
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821
Practice Address - Country:US
Practice Address - Phone:562-889-4256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24-12345678106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician