Provider Demographics
NPI:1972332583
Name:MINOSO, GUSTAVO
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:MINOSO
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 1:4174 NW 38TH PL
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33993-7422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4174 NW 38TH PL
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33993-7422
Practice Address - Country:US
Practice Address - Phone:832-378-0139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician