Provider Demographics
NPI:1326367673
Name:GAUDETTE, TONJA M (CIS)
Entity Type:Individual
Prefix:
First Name:TONJA
Middle Name:M
Last Name:GAUDETTE
Suffix:
Gender:F
Credentials:CIS
Other - Prefix:
Other - First Name:TONJA
Other - Middle Name:
Other - Last Name:BECWAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:36 LA MIRAGE CIR
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656
Mailing Address - Country:US
Mailing Address - Phone:714-296-3403
Mailing Address - Fax:
Practice Address - Street 1:6060 PARAMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805
Practice Address - Country:US
Practice Address - Phone:562-634-9534
Practice Address - Fax:562-790-1867
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CALCS689471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner