Provider Demographics
NPI:1316466428
Name:GONZALEZ, GABRIELLE ROSE (MASTERS)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:ROSE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MASTERS
Other - Prefix:
Other - First Name:MINDFUL REVAMP
Other - Middle Name:
Other - Last Name:INC.
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:INCORPORATION
Mailing Address - Street 1:7252 ARCHIBALD AVE # 1005
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-5017
Mailing Address - Country:US
Mailing Address - Phone:909-255-3861
Mailing Address - Fax:
Practice Address - Street 1:7252 ARCHIBALD AVE # 1005
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91701-5017
Practice Address - Country:US
Practice Address - Phone:909-255-3861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT100840106H00000X
CA122832106H00000X
CALMFT122832106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist