Provider Demographics
NPI:1629583562
Name:GONZALEZ, KATRINA MARIE
Entity Type:Individual
Prefix:MRS
First Name:KATRINA
Middle Name:MARIE
Last Name:GONZALEZ
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 1:222 E MAIN ST STE 117
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-2361
Mailing Address - Country:US
Mailing Address - Phone:760-255-1496
Mailing Address - Fax:760-255-2542
Practice Address - Street 1:222 E MAIN ST STE 117
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-2361
Practice Address - Country:US
Practice Address - Phone:760-255-1496
Practice Address - Fax:760-255-2542
Is Sole Proprietor?:No
Enumeration Date:2017-12-13
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA97776101YM0800X, 104100000X
CALCSW1184201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker