Provider Demographics
NPI:1285265819
Name:GONZALEZ, EDITH (AMFT)
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 MCCALL AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:CA
Mailing Address - Zip Code:93662-2560
Mailing Address - Country:US
Mailing Address - Phone:855-343-1057
Mailing Address - Fax:
Practice Address - Street 1:3400 MCCALL AVE STE 104
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:CA
Practice Address - Zip Code:93662-2560
Practice Address - Country:US
Practice Address - Phone:855-343-1057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-02
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA146159106H00000X, 106H00000X
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA146159OtherBOARD OF BEHAVIORAL SCIENCES
CA10372OtherCADTP