Provider Demographics
NPI:1053103630
Name:GONZALEZ, NADINE YADIRIS
Entity type:Individual
Prefix:
First Name:NADINE
Middle Name:YADIRIS
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 1:119 W TORRANCE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3600
Mailing Address - Country:US
Mailing Address - Phone:310-374-3300
Mailing Address - Fax:310-374-3307
Practice Address - Street 1:1000 S FREMONT AVE BLDG A-5
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-8800
Practice Address - Country:US
Practice Address - Phone:626-407-0740
Practice Address - Fax:626-407-0799
Is Sole Proprietor?:No
Enumeration Date:2025-05-20
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-24-388241106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician