MEDICARE: MARISSA MAXINE GONZALEZ

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1538863972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISSA MAXINE GONZALEZ

Provider Business Mailing Address
First Line	:	12070 TELEGRAPH RD
Second Line	:
City	:	SANTA FE SPRINGS
State	:	CA
Zip	:	90670-3771
Country	:	US
Telephone Number	:	562-777-7500
Fax Number	:

Provider Business Practice Location Address
First Line	:	2826 W VALLEY BLVD
Second Line	:
City	:	ALHAMBRA
State	:	CA
Zip	:	91803-1817
Country	:	US
Telephone Number	:	562-777-7500
Fax Number	:

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

Provider Enumeration Date	:	03/29/2023
Last Update Date	:	03/29/2023

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