Healthcare Provider Details

I. General information

NPI: 1891287751
Provider Name (Legal Business Name): WENDY GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 09/03/2021
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3924 RIVERVIEW DR
RIVERSIDE CA
92509-6611
US

IV. Provider business mailing address

3924 RIVERVIEW DR
RIVERSIDE CA
92509-6611
US

V. Phone/Fax

Practice location:
  • Phone: 951-360-4175
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5387
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: