Healthcare Provider Details

I. General information

NPI: 1790187151
Provider Name (Legal Business Name): HERMINIO GONZALEZ JR. LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2014
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 S SAN PEDRO ST
LOS ANGELES CA
90013-2119
US

IV. Provider business mailing address

1720 E 120TH ST
LOS ANGELES CA
90059-3052
US

V. Phone/Fax

Practice location:
  • Phone: 213-633-2950
  • Fax:
Mailing address:
  • Phone: 310-668-4272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW89355
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW72483
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: