Healthcare Provider Details

I. General information

NPI: 1205556024
Provider Name (Legal Business Name): BRANDI ANN GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2022
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 RUSTIN AVE STE 5
RIVERSIDE CA
92507-2498
US

IV. Provider business mailing address

5870 ARLINGTON AVE
RIVERSIDE CA
92504-2037
US

V. Phone/Fax

Practice location:
  • Phone: 951-509-2400
  • Fax: 951-509-2405
Mailing address:
  • Phone: 951-683-6596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1373101219
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: