Provider Demographics
NPI:1093830614
Name:GONZALEZ, GINA (MFT)
Entity Type:Individual
Prefix:MS
First Name:GINA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MRS
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:GONZALEZREYNA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:13920 OLD HARBOR LN APT 101
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-7323
Mailing Address - Country:US
Mailing Address - Phone:310-751-1167
Mailing Address - Fax:310-397-5827
Practice Address - Street 1:4160 GRAND VIEW BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5214
Practice Address - Country:US
Practice Address - Phone:310-751-1167
Practice Address - Fax:310-397-5827
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT47530106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist