Healthcare Provider Details

I. General information

NPI: 1104735612
Provider Name (Legal Business Name): MARINA GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARINA LOPEZ

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 S PACIFIC AVE
SAN PEDRO CA
90731-2656
US

IV. Provider business mailing address

1496 WALNUT AVE APT 7
LONG BEACH CA
90813-2454
US

V. Phone/Fax

Practice location:
  • Phone: 310-519-8723
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCI47070425
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: