Provider Demographics
NPI:1265770101
Name:GJELTEMA, TREVOR P (IMF)
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:P
Last Name:GJELTEMA
Suffix:
Gender:M
Credentials:IMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 28TH ST APT B
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-7338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1907 28TH ST APT B
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-7338
Practice Address - Country:US
Practice Address - Phone:831-234-4835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-28
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 69063106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA942519001Medicaid