Provider Demographics
NPI:1033770367
Name:GONZALEZ, JUAN ANTONIO LOERA (APCC 6611)
Entity Type:Individual
Prefix:
First Name:JUAN ANTONIO
Middle Name:LOERA
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:APCC 6611
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 S MANZANITA ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93292-7068
Mailing Address - Country:US
Mailing Address - Phone:559-202-6189
Mailing Address - Fax:
Practice Address - Street 1:209 E 7TH ST
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93638-3780
Practice Address - Country:US
Practice Address - Phone:559-673-3508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-26
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6611101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health