MEDICARE: BLAIRE L BROWN GONZALEZ M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	170300000X	Genetic Counselor (M.S.)

General Provider Information

NPI Number	:	1083693006
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLAIRE L BROWN GONZALEZ M.S.

Provider Business Mailing Address
First Line	:	13640 ROSCOE BLVD BLDG 3
Second Line	:
City	:	PANORAMA CITY
State	:	CA
Zip	:	91402-3904
Country	:	US
Telephone Number	:	818-375-3194
Fax Number	:

Provider Business Practice Location Address
First Line	:	13352 CANTARA ST
Second Line	:	S1- 104
City	:	PANORAMA CITY
State	:	CA
Zip	:	91402-5508
Country	:	US
Telephone Number	:	818-375-3194
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2006
Last Update Date	:	11/18/2021

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