Provider Demographics
NPI:1982231536
Name:GONZALEZ, OMAR
Entity Type:Individual
Prefix:MR
First Name:OMAR
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3818
Mailing Address - Country:US
Mailing Address - Phone:714-543-5437
Mailing Address - Fax:714-361-4376
Practice Address - Street 1:2130 E 4TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3818
Practice Address - Country:US
Practice Address - Phone:714-543-5437
Practice Address - Fax:714-361-4376
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health