Healthcare Provider Details

I. General information

NPI: 1447749312
Provider Name (Legal Business Name): TANYA GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2018
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9915 MIRA MESA BLVD STE 220
SAN DIEGO CA
92131-7002
US

IV. Provider business mailing address

9915 MIRA MESA BLVD STE 220
SAN DIEGO CA
92131-7002
US

V. Phone/Fax

Practice location:
  • Phone: 858-790-2013
  • Fax:
Mailing address:
  • Phone: 858-790-2013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY34920
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: