Provider Demographics
NPI:1619306289
Name:GONZALES, MARK (LAADC-CA LCI10970318)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:LAADC-CA LCI10970318
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4023 W DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-4185
Mailing Address - Country:US
Mailing Address - Phone:510-691-0474
Mailing Address - Fax:
Practice Address - Street 1:4023 W DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-4185
Practice Address - Country:US
Practice Address - Phone:510-691-0474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5465630291390200000X
CALCI10970318101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA168767OtherADDICTION COUNSELOR CERTIFICATION BOARD OF CALIFORNIA
CA168767OtherADDICTION COUNSELOR CERTIFICATION BOARD OF CALIFORNIA