Healthcare Provider Details

I. General information

NPI: 1851107395
Provider Name (Legal Business Name): KATHRYN ANTOINETTE GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date: 11/11/2025
Reactivation Date: 06/19/2026

III. Provider practice location address

47915 OASIS ST
INDIO CA
92201-6950
US

IV. Provider business mailing address

74058 KINGSTON CT W
PALM DESERT CA
92211-2050
US

V. Phone/Fax

Practice location:
  • Phone: 760-863-8680
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number130936
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: