Healthcare Provider Details

I. General information

NPI: 1699207936
Provider Name (Legal Business Name): DESERI ROSE GONZALES CCAPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 MAGNOLIA AVE
LONG BEACH CA
90806-4521
US

IV. Provider business mailing address

18646 OXNARD ST
TARZANA CA
91356-1411
US

V. Phone/Fax

Practice location:
  • Phone: 562-218-1868
  • Fax: 562-591-0346
Mailing address:
  • Phone: 818-996-1051
  • Fax: 818-996-1753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC5371214
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: