Provider Demographics
NPI:1104608843
Name:CLETO, ABIGAIL GANCENIA
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:GANCENIA
Last Name:CLETO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5068 NO NAME RD
Mailing Address - Street 2:
Mailing Address - City:LOOMIS
Mailing Address - State:CA
Mailing Address - Zip Code:95650-7911
Mailing Address - Country:US
Mailing Address - Phone:916-290-2389
Mailing Address - Fax:
Practice Address - Street 1:2202 PLAZA DR
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765-4404
Practice Address - Country:US
Practice Address - Phone:916-749-4646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician