Provider Demographics
NPI:1104076728
Name:GONELLA, MICOL (PSYD)
Entity type:Individual
Prefix:
First Name:MICOL
Middle Name:
Last Name:GONELLA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 721503
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92172-1503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16935 W BERNARDO DR
Practice Address - Street 2:SUITE 208
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-1634
Practice Address - Country:US
Practice Address - Phone:619-356-3539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-19
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY28522103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical