Provider Demographics
NPI:1740840933
Name:GAYTAN, GERARDO NICOLAS
Entity type:Individual
Prefix:
First Name:GERARDO
Middle Name:NICOLAS
Last Name:GAYTAN
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 1:10755 APPLE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-3684
Mailing Address - Country:US
Mailing Address - Phone:760-247-9840
Mailing Address - Fax:
Practice Address - Street 1:10755 APPLE VALLEY RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308-3684
Practice Address - Country:US
Practice Address - Phone:760-247-9840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6496101YP2500X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health