Provider Demographics
NPI:1235502659
Name:GONZALES, GARY
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7885 ANNANDALE AVE
Mailing Address - Street 2:
Mailing Address - City:DESERT HOT SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92240-1419
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7885 ANNANDALE AVE
Practice Address - Street 2:
Practice Address - City:DESERT HOT SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92240-1419
Practice Address - Country:US
Practice Address - Phone:760-329-2924
Practice Address - Fax:760-251-2932
Is Sole Proprietor?:No
Enumeration Date:2015-11-06
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR3631214101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)