Basic Information
| Provider Information | |||||||||
| NPI: | 1033770367 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | LOERA | ||||||||
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| Credential: | APCC 6611 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 224 S MANZANITA ST | ||||||||
| Address2: | |||||||||
| City: | VISALIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932927068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592026189 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2550 W CLINTON AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937054201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592647521 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2019 | ||||||||
| LastUpdateDate: | 08/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | 6611 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.