Provider Demographics
NPI:1831553890
Name:GONZALEZ-IDIART, CLARISSA (PHD)
Entity type:Individual
Prefix:DR
First Name:CLARISSA
Middle Name:
Last Name:GONZALEZ-IDIART
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23370 ROAD 22
Mailing Address - Street 2:
Mailing Address - City:CHOWCHILLA
Mailing Address - State:CA
Mailing Address - Zip Code:93610-8504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23370 ROAD 22
Practice Address - Street 2:
Practice Address - City:CHOWCHILLA
Practice Address - State:CA
Practice Address - Zip Code:93610-8504
Practice Address - Country:US
Practice Address - Phone:559-665-5531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1417318569OtherCDCR