Provider Demographics
NPI:1467004226
Name:GONZALEZ, LIZANDRA (AMFT)
Entity Type:Individual
Prefix:
First Name:LIZANDRA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17481 PAINE ST
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-2728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2008 N GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2722
Practice Address - Country:US
Practice Address - Phone:909-623-6131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA122289106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program