Provider Demographics
NPI:1225217052
Name:GONZALEZ, SUSAN M
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:M
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:SUSAN
Other - Middle Name:M
Other - Last Name:MUNOZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4029 W ROSECRANS AVE APT 17
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-7929
Mailing Address - Country:US
Mailing Address - Phone:714-567-1840
Mailing Address - Fax:
Practice Address - Street 1:815 N EL CENTRO AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-3805
Practice Address - Country:US
Practice Address - Phone:323-463-2119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA225400000X, 225400000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health