Provider Demographics
NPI:1417549874
Name:GONZALEZ, IVETT
Entity Type:Individual
Prefix:
First Name:IVETT
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3216 FLAXTON ST
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1414
Mailing Address - Country:US
Mailing Address - Phone:626-460-9012
Mailing Address - Fax:
Practice Address - Street 1:9631 BUSINESS CENTER DRIVE
Practice Address - Street 2:BLDG. 14, STE. D
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4554
Practice Address - Country:US
Practice Address - Phone:909-948-5747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-08
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW974971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAASW97497OtherBOARD OF BEHAVIORAL SCIENCES