Provider Demographics
NPI:1922810738
Name:LA O GAVILAN, JOAQUIN A
Entity type:Individual
Prefix:
First Name:JOAQUIN
Middle Name:A
Last Name:LA O GAVILAN
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 1:20318 BANNER AVE
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-4025
Mailing Address - Country:US
Mailing Address - Phone:786-547-9237
Mailing Address - Fax:
Practice Address - Street 1:20318 BANNER AVE
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-4025
Practice Address - Country:US
Practice Address - Phone:786-547-9237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician