MEDICARE: ESTEVAN GONZALEZ

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	171M00000X	Case Manager/Care Coordinator	R1563750624	CA
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	R1563750624	CA
3	175T00000X	Peer Specialist	MPSS-PDNXEL	CA

General Provider Information

NPI Number	:	1477272847
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ESTEVAN GONZALEZ

Provider Business Mailing Address
First Line	:	31764 CASINO DR STE 200
Second Line	:
City	:	LAKE ELSINORE
State	:	CA
Zip	:	92530-2312
Country	:	US
Telephone Number	:	951-471-4649
Fax Number	:

Provider Business Practice Location Address
First Line	:	31764 CASINO DR STE 200
Second Line	:
City	:	LAKE ELSINORE
State	:	CA
Zip	:	92530-2312
Country	:	US
Telephone Number	:	951-471-4649
Fax Number	:

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

Provider Enumeration Date	:	08/26/2022
Last Update Date	:	01/20/2026

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