Provider Demographics
NPI:1215472105
Name:GONZALEZ, MARTHA (PSYCHIATRIC TECH)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PSYCHIATRIC TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 E FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-5230
Mailing Address - Country:US
Mailing Address - Phone:909-421-9309
Mailing Address - Fax:909-421-9219
Practice Address - Street 1:2008 N GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2722
Practice Address - Country:US
Practice Address - Phone:909-623-6131
Practice Address - Fax:909-865-9281
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-30
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT34747167G00000X
167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician