Provider Demographics
NPI:1467110304
Name:GONZALES, CARINA
Entity Type:Individual
Prefix:
First Name:CARINA
Middle Name:
Last Name:GONZALES
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 1:111 DIVISION ST SPC 44
Mailing Address - Street 2:
Mailing Address - City:KING CITY
Mailing Address - State:CA
Mailing Address - Zip Code:93930-3021
Mailing Address - Country:US
Mailing Address - Phone:831-272-5061
Mailing Address - Fax:
Practice Address - Street 1:111 DIVISION ST SPC 44
Practice Address - Street 2:
Practice Address - City:KING CITY
Practice Address - State:CA
Practice Address - Zip Code:93930-3021
Practice Address - Country:US
Practice Address - Phone:831-272-5061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician