Provider Demographics
NPI:1770982928
Name:GONZALEZ, MYRNA BRIDGETTE
Entity type:Individual
Prefix:
First Name:MYRNA
Middle Name:BRIDGETTE
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 1:1040 BALBOA DR
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-1544
Mailing Address - Country:US
Mailing Address - Phone:408-849-2410
Mailing Address - Fax:
Practice Address - Street 1:101 S B ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-6933
Practice Address - Country:US
Practice Address - Phone:805-735-4376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF87732101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor