Provider Demographics
NPI:1033662275
Name:ACOSTA SIERRA, GONZALO (AMFT 143250)
Entity Type:Individual
Prefix:
First Name:GONZALO
Middle Name:
Last Name:ACOSTA SIERRA
Suffix:
Gender:M
Credentials:AMFT 143250
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92113-2209
Mailing Address - Country:US
Mailing Address - Phone:619-255-5172
Mailing Address - Fax:619-269-0464
Practice Address - Street 1:2130 NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-2209
Practice Address - Country:US
Practice Address - Phone:619-255-5172
Practice Address - Fax:619-269-0464
Is Sole Proprietor?:No
Enumeration Date:2016-07-23
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X, 390200000X, 101Y00000X
CA143250106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101Y00000XBehavioral Health & Social Service ProvidersCounselor