Basic Information
| Provider Information | |||||||||
| NPI: | 1104564665 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAPISTRAN | ||||||||
| FirstName: | GERARDO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3906 ALBILLO LOOP | ||||||||
| Address2: | |||||||||
| City: | PERRIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925717546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514835606 | ||||||||
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| Practice Location | |||||||||
| Address1: | 650 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925432960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517913300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2022 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.