Healthcare Provider Details

I. General information

NPI: 1972813756
Provider Name (Legal Business Name): MS. OLIVIA GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2010
Last Update Date: 10/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 N. MURRAY ST.
BANNING CA
92220
US

IV. Provider business mailing address

600 E. LUGONIA AVE. APT. B
REDLANDS CA
92374
US

V. Phone/Fax

Practice location:
  • Phone: 951-849-8812
  • Fax:
Mailing address:
  • Phone: 909-792-2597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number174H00000X
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: