Provider Demographics
NPI:1982057105
Name:GONZALEZ, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:MORENO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19322 JESSE LN
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-5072
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1820 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507
Practice Address - Country:US
Practice Address - Phone:951-955-7291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-22
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 106H00000X
CA152552106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst