Provider Demographics
NPI:1154946952
Name:GAYTAN, CARLOS JOEL (LCSW)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:JOEL
Last Name:GAYTAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1742
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91729-1742
Mailing Address - Country:US
Mailing Address - Phone:626-384-0843
Mailing Address - Fax:
Practice Address - Street 1:10801 6TH ST STE 120
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5987
Practice Address - Country:US
Practice Address - Phone:951-384-3286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA943751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical