Provider Demographics
NPI:1689705279
Name:GONZALES, REVA GARCIA
Entity Type:Individual
Prefix:MS
First Name:REVA
Middle Name:GARCIA
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 1:2678 GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MORRO BAY
Mailing Address - State:CA
Mailing Address - Zip Code:93442-1547
Mailing Address - Country:US
Mailing Address - Phone:805-772-8630
Mailing Address - Fax:
Practice Address - Street 1:115 E FESLER ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-4404
Practice Address - Country:US
Practice Address - Phone:805-922-6597
Practice Address - Fax:805-922-5978
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)