Healthcare Provider Details

I. General information

NPI: 1649568627
Provider Name (Legal Business Name): DIANA GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6601 STEPHENS RANCH RD
LA VERNE CA
91750-1146
US

IV. Provider business mailing address

711 S NEW HAMPSHIRE AVE
LOS ANGELES CA
90005-1831
US

V. Phone/Fax

Practice location:
  • Phone: 213-266-3038
  • Fax:
Mailing address:
  • Phone: 213-385-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number73846
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: