Provider Demographics
NPI:1053146951
Name:GAVILAN, NINO MALLILLIN
Entity type:Individual
Prefix:
First Name:NINO
Middle Name:MALLILLIN
Last Name: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 1:238 36TH AVE APT C
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-4248
Mailing Address - Country:US
Mailing Address - Phone:510-200-3989
Mailing Address - Fax:
Practice Address - Street 1:3701 HACIENDA ST
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-4366
Practice Address - Country:US
Practice Address - Phone:650-727-7992
Practice Address - Fax:650-319-9733
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)