Healthcare Provider Details

I. General information

NPI: 1952649667
Provider Name (Legal Business Name): OMAR GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2013
Last Update Date: 10/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 40TH ST
OAKLAND CA
94609-2633
US

IV. Provider business mailing address

390 40TH ST
OAKLAND CA
94609-2633
US

V. Phone/Fax

Practice location:
  • Phone: 510-653-5040
  • Fax: 510-653-6475
Mailing address:
  • Phone: 510-653-5040
  • Fax: 510-653-6475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: