=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538221387
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. OPHELIA MARIA GONZALES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 275 BECK AVE
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94533-6804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-399-4989
-----------------------------------------------------
Fax | 707-399-4957
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 999 MARSHALL RD 131
-----------------------------------------------------
City | VACAVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95687-5755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-450-6061
-----------------------------------------------------
Fax | 707-399-4957
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------