Healthcare Provider Details

I. General information

NPI: 1356233423
Provider Name (Legal Business Name): SERGIO GONZALES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2025
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 E ORANGETHORPE AVE STE 200
FULLERTON CA
92831-5205
US

IV. Provider business mailing address

1501 E ORANGETHORPE AVE STE 200
FULLERTON CA
92831-5205
US

V. Phone/Fax

Practice location:
  • Phone: 714-254-8473
  • Fax: 714-254-8480
Mailing address:
  • Phone: 714-254-8473
  • Fax: 714-254-8480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: