Provider Demographics
NPI:1043795891
Name:GONZALES, DIANA I
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:GONZALES
Suffix:I
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 1:9060 HUNTINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91775-1332
Mailing Address - Country:US
Mailing Address - Phone:626-943-7772
Mailing Address - Fax:
Practice Address - Street 1:9060 HUNTINGTON DR
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91775-1332
Practice Address - Country:US
Practice Address - Phone:626-943-7772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1467715813Medicaid