Provider Demographics
NPI:1770177644
Name:GONZALES, KATHERINE PETERSON
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:PETERSON
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 1:2425 BISSO LN STE 200
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-4886
Mailing Address - Country:US
Mailing Address - Phone:925-839-0588
Mailing Address - Fax:
Practice Address - Street 1:2425 BISSO LN STE 200
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-4886
Practice Address - Country:US
Practice Address - Phone:925-839-0588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-22
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106020104100000X
1041C0700X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program