Provider Demographics
NPI:1538630108
Name:GONZALEZ, KALIE CONSTANCE
Entity type:Individual
Prefix:
First Name:KALIE
Middle Name:CONSTANCE
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 1:2074 LOS ALTOS AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-5309
Mailing Address - Country:US
Mailing Address - Phone:559-223-1838
Mailing Address - Fax:
Practice Address - Street 1:20 N DEWITT AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-0311
Practice Address - Country:US
Practice Address - Phone:559-575-8172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician