Provider Demographics
NPI:1316449986
Name:GAUDIEL, KERSTINE MARI SAN DIEGO
Entity type:Individual
Prefix:
First Name:KERSTINE MARI
Middle Name:SAN DIEGO
Last Name:GAUDIEL
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 1:6600 W CHARLESTON BLVD STE 132
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-1067
Mailing Address - Country:US
Mailing Address - Phone:702-283-6215
Mailing Address - Fax:
Practice Address - Street 1:6600 W CHARLESTON BLVD STE 132
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-1067
Practice Address - Country:US
Practice Address - Phone:702-283-6215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician