Provider Demographics
NPI:1225255268
Name:GONZALES, FABIAN (ADDICTION SPECIALIST)
Entity Type:Individual
Prefix:MR
First Name:FABIAN
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:ADDICTION SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:25 EL NIDO AVENUE
Mailing Address - Street 2:APARTMENT #2
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107
Mailing Address - Country:US
Mailing Address - Phone:626-644-2545
Mailing Address - Fax:
Practice Address - Street 1:540 SOUTH EREMLAND DR.
Practice Address - Street 2:SUITE #A
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723
Practice Address - Country:US
Practice Address - Phone:626-966-1577
Practice Address - Fax:626-966-5184
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)