Provider Demographics
NPI:1295923787
Name:GONZALES, FAWN (LCSW LLC)
Entity type:Individual
Prefix:
First Name:FAWN
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LCSW LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 W BALBOA BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2436 W COAST HWY STE 103
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4771
Practice Address - Country:US
Practice Address - Phone:541-944-7711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL52121041C0700X
CA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical