Provider Demographics
NPI:1285442905
Name:GONZALEZ, SAMANTHA N
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:N
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:NICHOLE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3625 SANTA CRUZ CT
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-6220
Mailing Address - Country:US
Mailing Address - Phone:951-235-9503
Mailing Address - Fax:
Practice Address - Street 1:3625 SANTA CRUZ CT
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-6220
Practice Address - Country:US
Practice Address - Phone:951-235-9503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-27
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician