Provider Demographics
NPI:1124899075
Name:GONZALEZ, JOHAN
Entity type:Individual
Prefix:
First Name:JOHAN
Middle Name:
Last Name:GONZALEZ
Suffix:
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 1:16600 SHERMAN WAY STE 178
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-3875
Mailing Address - Country:US
Mailing Address - Phone:818-235-1414
Mailing Address - Fax:323-866-1881
Practice Address - Street 1:6370 MAGNOLIA AVE STE 340
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2404
Practice Address - Country:US
Practice Address - Phone:888-428-3223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician