Provider Demographics
NPI:1003702242
Name:GONZALEZ, OLIVIA ANGELISE
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:ANGELISE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30033 MONTE VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:THOUSAND PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92276-2901
Mailing Address - Country:US
Mailing Address - Phone:760-660-1552
Mailing Address - Fax:
Practice Address - Street 1:11799 SEBASTIAN WAY STE 103
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0708
Practice Address - Country:US
Practice Address - Phone:909-353-7547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician