Provider Demographics
NPI:1447610498
Name:GONZALEZ, PEDRO
Entity Type:Individual
Prefix:
First Name:PEDRO
Middle Name:
Last Name:GONZALEZ
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 1:4843 EL MORADO ST
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-3115
Mailing Address - Country:US
Mailing Address - Phone:626-487-0025
Mailing Address - Fax:
Practice Address - Street 1:11041 VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-2516
Practice Address - Country:US
Practice Address - Phone:626-442-4177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-03
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC13451214101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)