Healthcare Provider Details

I. General information

NPI: 1255011367
Provider Name (Legal Business Name): TAMARA ELISSE GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 02/02/2026
Certification Date: 02/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8326 BANYAN ST
ALTA LOMA CA
91701-2602
US

IV. Provider business mailing address

8326 BANYAN ST
ALTA LOMA CA
91701-2602
US

V. Phone/Fax

Practice location:
  • Phone: 909-732-5936
  • Fax:
Mailing address:
  • Phone: 909-732-5936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number136056
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: