Provider Demographics
NPI:1013700889
Name:GONZALEZ, ELISA AILEEN
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:AILEEN
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 1:21 E SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-4607
Mailing Address - Country:US
Mailing Address - Phone:209-221-2275
Mailing Address - Fax:
Practice Address - Street 1:5815 STODDARD RD STE 600
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9041
Practice Address - Country:US
Practice Address - Phone:209-348-9786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-26
Last Update Date:2025-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT154321106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist