Provider Demographics
NPI:1467269043
Name:GONZALEZ, KEILA ELISE FORTUNE
Entity type:Individual
Prefix:MISS
First Name:KEILA
Middle Name:ELISE FORTUNE
Last Name: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 1:28 WESTBROOK LN
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-4887
Mailing Address - Country:US
Mailing Address - Phone:909-973-2752
Mailing Address - Fax:
Practice Address - Street 1:801 CORPORATE CENTER DR
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-2628
Practice Address - Country:US
Practice Address - Phone:909-618-0974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician