Provider Demographics
NPI:1861106825
Name:CHAVEZ, GABRIEL MARTIN (RADT)
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:MARTIN
Last Name:CHAVEZ
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 W AVENUE L
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-6247
Mailing Address - Country:US
Mailing Address - Phone:661-993-2492
Mailing Address - Fax:
Practice Address - Street 1:1616 W AVENUE L
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-6247
Practice Address - Country:US
Practice Address - Phone:661-983-2492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1387000420101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE3955164OtherDRIVER LICENSE