Healthcare Provider Details

I. General information

NPI: 1386379428
Provider Name (Legal Business Name): DEYANIRA GONZALEZ-MORA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2022
Last Update Date: 07/22/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 STINE RD
BAKERSFIELD CA
93309-4827
US

IV. Provider business mailing address

5116 VILLA BELLA LN
BAKERSFIELD CA
93311-9595
US

V. Phone/Fax

Practice location:
  • Phone: 866-707-6664
  • Fax:
Mailing address:
  • Phone: 661-342-6138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW107680
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: