Provider Demographics
NPI:1710292198
Name:VARGAS DE GONZALEZ, MARIA LETICIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:LETICIA
Last Name:VARGAS DE 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 1:24301 SOUTHLAND DR STE 300
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94545-1546
Mailing Address - Country:US
Mailing Address - Phone:510-881-5921
Mailing Address - Fax:510-881-5925
Practice Address - Street 1:24301 SOUTHLAND DR STE 300
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545-1546
Practice Address - Country:US
Practice Address - Phone:510-881-5921
Practice Address - Fax:510-881-5925
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor