Provider Demographics
NPI:1295768513
Name:GONSALVES, SUSIE ANN (LCSW)
Entity type:Individual
Prefix:MS
First Name:SUSIE
Middle Name:ANN
Last Name:GONSALVES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32605 HIGHWAY 79 SOUTH
Mailing Address - Street 2:SUITE 206
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592
Mailing Address - Country:US
Mailing Address - Phone:951-302-6400
Mailing Address - Fax:951-302-6400
Practice Address - Street 1:32605 HIGHWAY 79 SOUTH
Practice Address - Street 2:SUITE 206
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592
Practice Address - Country:US
Practice Address - Phone:951-302-6400
Practice Address - Fax:951-302-6400
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS18971101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health