Provider Demographics
NPI:1497188312
Name:GONZALEZ, MARCO
Entity Type:Individual
Prefix:
First Name:MARCO
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 1:921 W AVENUE J STE C
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-3443
Mailing Address - Country:US
Mailing Address - Phone:661-254-7086
Mailing Address - Fax:661-254-7108
Practice Address - Street 1:921 W AVENUE J STE C
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3443
Practice Address - Country:US
Practice Address - Phone:661-254-7086
Practice Address - Fax:661-254-7108
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst