Healthcare Provider Details

I. General information

NPI: 1316825367
Provider Name (Legal Business Name): DOLORES BRISENO GONZALES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DOLORES BRISENO

II. Dates (important events)

Enumeration Date: 08/26/2025
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24910 LAS BRISAS RD STE 117
MURRIETA CA
92562-4035
US

IV. Provider business mailing address

597 WOODCREST DR APT 3
LAKE ELSINORE CA
92530-7004
US

V. Phone/Fax

Practice location:
  • Phone: 951-465-3664
  • Fax:
Mailing address:
  • Phone: 951-358-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number120159
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: