Provider Demographics
NPI:1386185411
Name:GONZALEZ, SANTIAGO IV (AMFT)
Entity Type:Individual
Prefix:
First Name:SANTIAGO
Middle Name:
Last Name:GONZALEZ
Suffix:IV
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 N MAGNOLIA AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-3610
Mailing Address - Country:US
Mailing Address - Phone:619-440-5133
Mailing Address - Fax:
Practice Address - Street 1:460 N MAGNOLIA AVE STE 110
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-3610
Practice Address - Country:US
Practice Address - Phone:619-440-5133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110202106H00000X
CA390200000X
CAAMFT110202101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program