Basic Information
| Provider Information | |||||||||
| NPI: | 1902098726 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALES | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LVN, RAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 161 N DATE ST | ||||||||
| Address2: | |||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920253405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607457786 | ||||||||
| FaxNumber: | 7607451061 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 E OHIO AVE STE 104 | ||||||||
| Address2: | |||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607457786 | ||||||||
| FaxNumber: | 7607451061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2007 | ||||||||
| LastUpdateDate: | 09/04/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | GO402241157 | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 164X00000X | VN181643 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.