Provider Demographics
NPI:1932525110
Name:GONZAGO, KATRINA
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:GONZAGO
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 1:700 LAWRENCE EXPY
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-5173
Mailing Address - Country:US
Mailing Address - Phone:408-851-7053
Mailing Address - Fax:408-851-7051
Practice Address - Street 1:700 LAWRENCE EXPY
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95051-5173
Practice Address - Country:US
Practice Address - Phone:408-851-7053
Practice Address - Fax:408-851-7051
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 249441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical