Healthcare Provider Details

I. General information

NPI: 1891163374
Provider Name (Legal Business Name): BRENDA GONZALEZ BARAJAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2015
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 N EUCLID AVE
ONTARIO CA
91762-2729
US

IV. Provider business mailing address

1543 E FAIRFIELD CT APT 4
ONTARIO CA
91761-4903
US

V. Phone/Fax

Practice location:
  • Phone: 909-983-2020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number78588
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number99236
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: