Provider Demographics
NPI:1699207936
Name:GONZALES, DESERI ROSE (CCAPP)
Entity Type:Individual
Prefix:
First Name:DESERI
Middle Name:ROSE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:CCAPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18646 OXNARD ST
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-1411
Mailing Address - Country:US
Mailing Address - Phone:818-996-1051
Mailing Address - Fax:818-996-1753
Practice Address - Street 1:2101 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-4521
Practice Address - Country:US
Practice Address - Phone:562-218-1868
Practice Address - Fax:562-591-0346
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CAC5371214101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172V00000XOther Service ProvidersCommunity Health Worker