Provider Demographics
NPI:1437720950
Name:GONZALEZ, TANYA
Entity Type:Individual
Prefix:
First Name:TANYA
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 1:1115 S ETHEL AVE
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-2036
Mailing Address - Country:US
Mailing Address - Phone:626-776-8445
Mailing Address - Fax:
Practice Address - Street 1:160 S 7TH AVE
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91746-3211
Practice Address - Country:US
Practice Address - Phone:626-961-8971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT135989106H00000X
225400000X, 390200000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program