Provider Demographics
NPI:1003117391
Name:GONZALEZ, KRYSTELINA
Entity Type:Individual
Prefix:MISS
First Name:KRYSTELINA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRYSTELINA
Other - Middle Name:
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:15480 RAMONA AVE
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-2421
Mailing Address - Country:US
Mailing Address - Phone:760-243-8140
Mailing Address - Fax:
Practice Address - Street 1:15480 RAMONA AVE
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2421
Practice Address - Country:US
Practice Address - Phone:760-243-8140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-03
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107677106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA390200000XOtherMFT TRAINEE
CA106H00000XOtherMFT INTERN