Provider Demographics
NPI:1245767342
Name:GONGORA, RALPH
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:
Last Name:GONGORA
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 1:6926 GRETNA AVE
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90606-1905
Mailing Address - Country:US
Mailing Address - Phone:562-665-6836
Mailing Address - Fax:562-692-7283
Practice Address - Street 1:15229 E. AMAR ROAD
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744
Practice Address - Country:US
Practice Address - Phone:626-855-5090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-19
Last Update Date:2017-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)