Healthcare Provider Details

I. General information

NPI: 1235954371
Provider Name (Legal Business Name): SAMANTHA GABRIELA GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2024
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 MERIDIAN AVE STE 302
SAN JOSE CA
95125-5350
US

IV. Provider business mailing address

224 CALLAN AVE APT 7
SAN LEANDRO CA
94577-4537
US

V. Phone/Fax

Practice location:
  • Phone: 628-587-7279
  • Fax:
Mailing address:
  • Phone: 279-234-1825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: