Provider Demographics
NPI:1831720952
Name:GONZALES, STEPHANIE ANDREA (BS)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANDREA
Last Name:GONZALES
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8780 19TH ST STE 1996
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-4608
Mailing Address - Country:US
Mailing Address - Phone:909-773-8597
Mailing Address - Fax:
Practice Address - Street 1:7062 NAPA AVE
Practice Address - Street 2:
Practice Address - City:ALTA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91701-5431
Practice Address - Country:US
Practice Address - Phone:909-773-8597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1146601041C0700X, 104100000X, 104100000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator