Provider Demographics
NPI:1699899674
Name:GUDINO, OMAR GABRIEL (PHD, ABPP)
Entity type:Individual
Prefix:DR
First Name:OMAR
Middle Name:GABRIEL
Last Name:GUDINO
Suffix:
Gender:M
Credentials:PHD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 ALAMEDA DE LAS PULGAS STE 242
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-1271
Mailing Address - Country:US
Mailing Address - Phone:650-931-6565
Mailing Address - Fax:
Practice Address - Street 1:2000 ALAMEDA DE LAS PULGAS STE 242
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-1271
Practice Address - Country:US
Practice Address - Phone:650-931-6565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34415103TB0200X, 103TC2200X
NY018596103TB0200X, 103TC2200X
CO3707103TC2200X
MO2018040406103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral