Provider Demographics
NPI:1700096807
Name:GONZALEZ, VERONICA L
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:L
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 1:101 E. REDLANDS BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-0369
Mailing Address - Country:US
Mailing Address - Phone:909-793-1078
Mailing Address - Fax:
Practice Address - Street 1:1323 W COLTON AVE STE 100
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-2853
Practice Address - Country:US
Practice Address - Phone:909-335-7067
Practice Address - Fax:909-792-2045
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CAIMF 75405106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4753OtherSIMON STAFF NUMBER