Provider Demographics
NPI:1780161745
Name:GONZALEZ, NATHALIE LESLIE
Entity type:Individual
Prefix:
First Name:NATHALIE
Middle Name:LESLIE
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 1:2560 W SHAW LN STE 104
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-2777
Mailing Address - Country:US
Mailing Address - Phone:559-443-4800
Mailing Address - Fax:
Practice Address - Street 1:2560 W SHAW LN STE 104
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-2777
Practice Address - Country:US
Practice Address - Phone:559-443-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-23
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA171400000X
CAMPSS-AIKVUY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171400000XOther Service ProvidersHealth & Wellness Coach