Healthcare Provider Details

I. General information

NPI: 1437807674
Provider Name (Legal Business Name): CRISTA GONZALEZ LEP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2022
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 S CATALINA AVE STE 118
REDONDO BEACH CA
90277-3388
US

IV. Provider business mailing address

5110 PATRICK ST
TORRANCE CA
90503-1931
US

V. Phone/Fax

Practice location:
  • Phone: 310-367-2368
  • Fax:
Mailing address:
  • Phone: 310-367-2368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLEP3469
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLEP3469
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number3469
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number3469
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: