Healthcare Provider Details

I. General information

NPI: 1871036277
Provider Name (Legal Business Name): ELIZABETH GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2016
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19401 S VERMONT AVE # L102
TORRANCE CA
90502-1029
US

IV. Provider business mailing address

13452 PALOMAR ST
WESTMINSTER CA
92683-2517
US

V. Phone/Fax

Practice location:
  • Phone: 310-323-6887
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMF95680
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number116673
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: