Basic Information
| Provider Information | |||||||||
| NPI: | 1295116440 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAZURTO | ||||||||
| FirstName: | GABRIEL | ||||||||
| MiddleName: | JACOB | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LISAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 S 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857134730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206283400 | ||||||||
| FaxNumber: | 5206283401 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 S 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857134730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206283400 | ||||||||
| FaxNumber: | 5206283401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2015 | ||||||||
| LastUpdateDate: | 06/13/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LISAC-11077 | AZ | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.