Provider Demographics
NPI:1801502992
Name:GONZALEZ, STEFANIE R
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:R
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 1:3641 WESTWOOD BLVD APT 1
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-6738
Mailing Address - Country:US
Mailing Address - Phone:310-560-1360
Mailing Address - Fax:
Practice Address - Street 1:1080 S LA CIENEGA BLVD STE 208
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-2680
Practice Address - Country:US
Practice Address - Phone:323-426-6402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-22-200801106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician