Provider Demographics
NPI:1972106326
Name:GONZALEZ, MARINA
Entity Type:Individual
Prefix:
First Name:MARINA
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 1:1629 ANN ARBOR CT
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-2367
Mailing Address - Country:US
Mailing Address - Phone:951-357-3291
Mailing Address - Fax:
Practice Address - Street 1:1629 ANN ARBOR CT
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-2367
Practice Address - Country:US
Practice Address - Phone:951-357-3291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY8708786363AM0700X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical