Provider Demographics
NPI:1043400591
Name:GONZALEZ, HENRY A (RAS)
Entity Type:Individual
Prefix:MR
First Name:HENRY
Middle Name:A
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 N D ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92401-1111
Mailing Address - Country:US
Mailing Address - Phone:909-381-5507
Mailing Address - Fax:909-888-5938
Practice Address - Street 1:1021 W LA CADENA DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-1413
Practice Address - Country:US
Practice Address - Phone:951-784-8010
Practice Address - Fax:951-784-2859
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGO412291733171M00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGO412291733OtherSUBSTANCE ABUSE COUNSELOR