Provider Demographics
NPI:1700155348
Name:GONZALES, LISA
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:GONZALES
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 1:118 S COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-5503
Mailing Address - Country:US
Mailing Address - Phone:562-256-7550
Mailing Address - Fax:
Practice Address - Street 1:118 S COLLEGE ST
Practice Address - Street 2:
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-5503
Practice Address - Country:US
Practice Address - Phone:562-256-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA576224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA576Medicaid
CA576Medicaid