Provider Demographics
NPI:1366110538
Name:SANTOS, GABRIEL
Entity type:Individual
Prefix:MR
First Name:GABRIEL
Middle Name:
Last Name:SANTOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18152 LULL ST
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-2048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18152 LULL ST
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-2048
Practice Address - Country:US
Practice Address - Phone:510-314-6423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-02
Last Update Date:2021-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YP2500X, 175T00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01779778Medicaid