Healthcare Provider Details

I. General information

NPI: 1609299585
Provider Name (Legal Business Name): LISSETTE RUBIO GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2014
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17862 17TH ST STE 107
TUSTIN CA
92780-2170
US

IV. Provider business mailing address

831 E ARROW HWY
POMONA CA
91767-2535
US

V. Phone/Fax

Practice location:
  • Phone: 714-661-5390
  • Fax: 714-661-5449
Mailing address:
  • Phone: 909-398-4383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT136729
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: