MEDICARE: MARIELENA GONZALEZ SLPA

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	2355S0801X	Speech-Language Assistant	8661	CA

General Provider Information

NPI Number	:	1093562696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIELENA GONZALEZ SLPA

Provider Business Mailing Address
First Line	:	2966 ANNA ST
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-4401
Country	:	US
Telephone Number	:	951-905-0758
Fax Number	:

Provider Business Practice Location Address
First Line	:	2966 ANNA ST
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-4401
Country	:	US
Telephone Number	:	951-905-0758
Fax Number	:

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

Provider Enumeration Date	:	05/01/2024
Last Update Date	:	05/01/2024

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