Healthcare Provider Details

I. General information

NPI: 1881241693
Provider Name (Legal Business Name): MARTIN A GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2019
Last Update Date: 04/03/2020
Certification Date: 04/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 N VAN NESS AVE
FRESNO CA
93728-3429
US

IV. Provider business mailing address

7120 N MARKS AVE STE 110
FRESNO CA
93711-0268
US

V. Phone/Fax

Practice location:
  • Phone: 559-268-7613
  • Fax:
Mailing address:
  • Phone: 559-439-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number113031
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: