Basic Information
| Provider Information | |||||||||
| NPI: | 1073154282 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VEA GASTELUM | ||||||||
| FirstName: | PERLA | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | VEA FIERRO | ||||||||
| OtherFirstName: | PERLA | ||||||||
| OtherMiddleName: | SUJEY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1408 | ||||||||
| Address2: | |||||||||
| City: | MAMMOTH LAKES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935461408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607090896 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 162J GROVE ST | ||||||||
| Address2: | |||||||||
| City: | BISHOP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935142640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608736533 | ||||||||
| FaxNumber: | 7608733277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2019 | ||||||||
| LastUpdateDate: | 09/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.