Healthcare Provider Details

I. General information

NPI: 1235786120
Provider Name (Legal Business Name): MRS. BRIANA KORINNA GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2019
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17647 MCWETHY DR APT 3
FONTANA CA
92336-2781
US

IV. Provider business mailing address

17647 MCWETHY DR APT 3
FONTANA CA
92336-2781
US

V. Phone/Fax

Practice location:
  • Phone: 626-438-5855
  • Fax:
Mailing address:
  • Phone: 626-438-5855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number41436
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: