Provider Demographics
NPI:1154999175
Name:GAVINO VARGAS, ILSE MARIANA
Entity type:Individual
Prefix:
First Name:ILSE
Middle Name:MARIANA
Last Name:GAVINO VARGAS
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 1:4260 CLAYTON RD APT 13
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94521-2715
Mailing Address - Country:US
Mailing Address - Phone:925-726-7897
Mailing Address - Fax:
Practice Address - Street 1:2005 MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:OAKLEY
Practice Address - State:CA
Practice Address - Zip Code:94561-3301
Practice Address - Country:US
Practice Address - Phone:925-776-8223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker