Healthcare Provider Details

I. General information

NPI: 1003324872
Provider Name (Legal Business Name): CARMEN ANN GONZALES I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 01/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 S ANAHEIM BLVD
ANAHEIM CA
92805-5806
US

IV. Provider business mailing address

626 N PACIFIC AVE
GLENDALE CA
91203-1618
US

V. Phone/Fax

Practice location:
  • Phone: 714-533-6220
  • Fax:
Mailing address:
  • Phone: 626-590-4186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number62475
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: