MEDICARE: MR. OMAR GONZALEZ LCSW

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	1041C0700X	Clinical Social Worker	25526	CA

General Provider Information

NPI Number	:	1366124687
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. OMAR GONZALEZ LCSW

Provider Business Mailing Address
First Line	:	PO BOX 3261
Second Line	:
City	:	PALM SPRINGS
State	:	CA
Zip	:	92263-3261
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3131 CAMINO DEL RIO N
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-5701
Country	:	US
Telephone Number	:	951-837-8810
Fax Number	:

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

Provider Enumeration Date	:	08/04/2023
Last Update Date	:	08/22/2023

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