Provider Demographics
NPI:1366199135
Name:DE HARO, GABRIEL ALAN
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:ALAN
Last Name:DE HARO
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 1:1215 S NORTON AVE APT 307
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-3339
Mailing Address - Country:US
Mailing Address - Phone:310-621-0748
Mailing Address - Fax:
Practice Address - Street 1:1215 S NORTON AVE APT 307
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019-3339
Practice Address - Country:US
Practice Address - Phone:310-621-0748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55897225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist