MEDICARE: ILENE 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	106H00000X	Marriage & Family Therapist	111699	CA

General Provider Information

NPI Number	:	1528524824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ILENE GONZALEZ

Provider Business Mailing Address
First Line	:	115 PINE AVE STE 440
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90802-4457
Country	:	US
Telephone Number	:	562-349-3032
Fax Number	:	562-432-0089

Provider Business Practice Location Address
First Line	:	115 PINE AVE STE 440
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90802-4457
Country	:	US
Telephone Number	:	562-349-3032
Fax Number	:	562-432-0089

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

Provider Enumeration Date	:	02/12/2019
Last Update Date	:	02/12/2019

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Directions to “ ILENE GONZALEZ ” Practice Location

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