MEDICARE: MR. FRED DANIEL GONZALES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

General Provider Information

NPI Number	:	1346507605
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. FRED DANIEL GONZALES

Provider Business Mailing Address
First Line	:	1180 3RD AVE
Second Line	:	SUITE C3
City	:	CHULA VISTA
State	:	CA
Zip	:	91911-3139
Country	:	US
Telephone Number	:	619-691-8164
Fax Number	:	619-426-2359

Provider Business Practice Location Address
First Line	:	1180 3RD AVE
Second Line	:	SUITE C3
City	:	CHULA VISTA
State	:	CA
Zip	:	91911-3139
Country	:	US
Telephone Number	:	619-691-8164
Fax Number	:	619-426-2359

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2012
Last Update Date	:	04/11/2012

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