Provider Demographics
NPI:1093310484
Name:GONZALES, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:GONZALES
Suffix:
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 1:27905 MANDARIN AVE
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544-5064
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2202 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95131-2007
Practice Address - Country:US
Practice Address - Phone:408-200-8637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)