Provider Demographics
NPI:1104525377
Name:GONZALES, MARCO ANTONIO JR
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:ANTONIO
Last Name:GONZALES
Suffix:JR
Gender:M
Credentials:
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 1653
Mailing Address - Street 2:
Mailing Address - City:LATHROP
Mailing Address - State:CA
Mailing Address - Zip Code:95330-1653
Mailing Address - Country:US
Mailing Address - Phone:209-751-6979
Mailing Address - Fax:
Practice Address - Street 1:730 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-4104
Practice Address - Country:US
Practice Address - Phone:209-650-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA113428104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker