MEDICARE: NELLIE 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	104100000X	Social Worker

General Provider Information

NPI Number	:	1700187101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NELLIE GONZALEZ

Provider Business Mailing Address
First Line	:	3375 S HOOVER ST # H201
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90089-0116
Country	:	US
Telephone Number	:	866-740-6502
Fax Number	:

Provider Business Practice Location Address
First Line	:	3375 S HOOVER ST # H201
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90089-0116
Country	:	US
Telephone Number	:	866-740-6502
Fax Number	:

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

Provider Enumeration Date	:	11/16/2010
Last Update Date	:	05/21/2013

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