Provider Demographics
NPI:1962826495
Name:GONZALEZ, MICAELA
Entity Type:Individual
Prefix:
First Name:MICAELA
Middle Name:
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 1:1465 30TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-3497
Mailing Address - Country:US
Mailing Address - Phone:619-275-0822
Mailing Address - Fax:619-275-5069
Practice Address - Street 1:1465 30TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-3497
Practice Address - Country:US
Practice Address - Phone:619-275-0822
Practice Address - Fax:619-275-5069
Is Sole Proprietor?:No
Enumeration Date:2014-02-04
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 390200000X
CAIMF #88983101YM0800X
CA102669106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program