Provider Demographics
NPI:1144759556
Name:GONICMAN, YAEL
Entity Type:Individual
Prefix:
First Name:YAEL
Middle Name:
Last Name:GONICMAN
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 1:102 ROCK HARBOR LN
Mailing Address - Street 2:
Mailing Address - City:FOSTER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94404-3569
Mailing Address - Country:US
Mailing Address - Phone:858-337-5453
Mailing Address - Fax:
Practice Address - Street 1:355 GELLERT BLVD STE 257
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2676
Practice Address - Country:US
Practice Address - Phone:628-242-2662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA120198106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist