Provider Demographics
NPI:1457744583
Name:ENGELAUF-GONZALEZ, GRISELDA
Entity Type:Individual
Prefix:
First Name:GRISELDA
Middle Name:
Last Name:ENGELAUF-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 1:5015 CANYON CREST DR STE 105
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-6006
Mailing Address - Country:US
Mailing Address - Phone:909-649-3863
Mailing Address - Fax:909-614-7609
Practice Address - Street 1:5015 CANYON CREST DR STE 105
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-6006
Practice Address - Country:US
Practice Address - Phone:909-649-3863
Practice Address - Fax:909-614-7609
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-13
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT99290106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA83-2919488OtherLMFT
CA93-2357680OtherINC.