Basic Information
| Provider Information | |||||||||
| NPI: | 1083850846 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GASTELUM | ||||||||
| FirstName: | GUADALUPE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35234 EUREKA AVE | ||||||||
| Address2: | |||||||||
| City: | YUCAIPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923994783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098107936 | ||||||||
| FaxNumber: | 9097972480 | ||||||||
| Practice Location | |||||||||
| Address1: | 13800 HEACOCK ST | ||||||||
| Address2: | SUITE C236 | ||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925533339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516530819 | ||||||||
| FaxNumber: | 9516562614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2008 | ||||||||
| LastUpdateDate: | 12/23/2010 | ||||||||
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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 | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.