Provider Demographics
NPI:1962912212
Name:GONZALEZ, SAMANTHA KATHLEEN MARIE (BCBA)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:KATHLEEN MARIE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12432 BELLFLOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90242-2806
Mailing Address - Country:US
Mailing Address - Phone:800-288-4760
Mailing Address - Fax:
Practice Address - Street 1:12432 BELLFLOWER BLVD
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242-2806
Practice Address - Country:US
Practice Address - Phone:800-288-4760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-01
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-17-27586103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst