Provider Demographics
NPI:1972813756
Name:GONZALEZ, OLIVIA
Entity Type:Individual
Prefix:MS
First Name:OLIVIA
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 1:600 E. LUGONIA AVE.
Mailing Address - Street 2:APT. B
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374
Mailing Address - Country:US
Mailing Address - Phone:909-792-2597
Mailing Address - Fax:
Practice Address - Street 1:245 N. MURRAY ST.
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220
Practice Address - Country:US
Practice Address - Phone:951-849-8812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174H00000X101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)