Provider Demographics
NPI:1285986414
Name:GONZALEZ, PERSEPHONE B
Entity type:Individual
Prefix:
First Name:PERSEPHONE
Middle Name:B
Last Name:GONZALEZ
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 1:141 BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:MOSS LANDING
Mailing Address - State:CA
Mailing Address - Zip Code:95039-9604
Mailing Address - Country:US
Mailing Address - Phone:831-296-2325
Mailing Address - Fax:
Practice Address - Street 1:4169 VIGA CT STE A
Practice Address - Street 2:
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-3560
Practice Address - Country:US
Practice Address - Phone:831-296-2325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71250106H00000X
CA100405106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist