Provider Demographics
NPI:1871066217
Name:GAYTAN, IMELDA LETICIA
Entity type:Individual
Prefix:
First Name:IMELDA
Middle Name:LETICIA
Last Name:GAYTAN
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 1:435 MIGNOT LN
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95111-2417
Mailing Address - Country:US
Mailing Address - Phone:669-294-9560
Mailing Address - Fax:
Practice Address - Street 1:1401 PARKMOOR AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-3403
Practice Address - Country:US
Practice Address - Phone:408-318-3034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician