Provider Demographics
NPI:1700079316
Name:GONZALES, COREY STEPHEN (PHD)
Entity type:Individual
Prefix:DR
First Name:COREY
Middle Name:STEPHEN
Last Name:GONZALES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 E COMMERCECENTER DR STE 255
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-1660
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5001 E COMMERCECENTER DR STE 255
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309
Practice Address - Country:US
Practice Address - Phone:661-323-2108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-27
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 14557103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL145570Medicare PIN