Provider Demographics
NPI:1083292718
Name:GONZALEZ, MAYRA (LCSW)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1179 N MCDOWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-6559
Mailing Address - Country:US
Mailing Address - Phone:707-559-7500
Mailing Address - Fax:707-559-7620
Practice Address - Street 1:1179 N MCDOWELL BLVD
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-6559
Practice Address - Country:US
Practice Address - Phone:707-559-7500
Practice Address - Fax:707-559-7620
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA924581041C0700X
CA1082141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical