Provider Demographics
NPI:1093466294
Name:GONZALEZ, ANGEL SAMANTHA (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:SAMANTHA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19737 CAMINO DE ROSA
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-2106
Mailing Address - Country:US
Mailing Address - Phone:626-622-6628
Mailing Address - Fax:
Practice Address - Street 1:835 W CHRISTOPHER ST
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3702
Practice Address - Country:US
Practice Address - Phone:626-943-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-21-55127103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst