Provider Demographics
NPI:1104111418
Name:GONZALES, PETRA MARICIA
Entity type:Individual
Prefix:
First Name:PETRA
Middle Name:MARICIA
Last Name:GONZALES
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 1:13585 SAN PABLO AVE FIRST FLOOR
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806
Mailing Address - Country:US
Mailing Address - Phone:510-942-4600
Mailing Address - Fax:510-942-4601
Practice Address - Street 1:13585 SAN PABLO AVE FIRST FLOOR
Practice Address - Street 2:
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-9480
Practice Address - Country:US
Practice Address - Phone:510-942-4600
Practice Address - Fax:510-942-4601
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1145571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical