Basic Information
| Provider Information | |||||||||
| NPI: | 1598125148 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALES | ||||||||
| FirstName: | GENEVA | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | GONZALES | ||||||||
| OtherFirstName: | GENEVA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | 5990-R | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10511 MILLS AVE | ||||||||
| Address2: | |||||||||
| City: | WHITTIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906042440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629447953 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10511 MILLS AVE | ||||||||
| Address2: | |||||||||
| City: | WHITTIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906042440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629447953 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2016 | ||||||||
| LastUpdateDate: | 02/24/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 5990-R | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 5990-R | 01 | CA | CAADE | OTHER |