Provider Demographics
NPI:1982984985
Name:KOGAN, GABRIEL (MA, RAS)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:KOGAN
Suffix:
Gender:M
Credentials:MA, RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11905 BLAKE RD
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CA
Mailing Address - Zip Code:95693-8537
Mailing Address - Country:US
Mailing Address - Phone:916-346-2105
Mailing Address - Fax:
Practice Address - Street 1:1161 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-3136
Practice Address - Country:US
Practice Address - Phone:619-498-5072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-22
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARI-K1108111257101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)