Provider Demographics
NPI:1982890661
Name:GONZALEZ, VICKIE (MFT)
Entity type:Individual
Prefix:MS
First Name:VICKIE
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4680 ELEANOR DR
Mailing Address - Street 2:
Mailing Address - City:CARPINTERIA
Mailing Address - State:CA
Mailing Address - Zip Code:93013
Mailing Address - Country:US
Mailing Address - Phone:805-895-5172
Mailing Address - Fax:
Practice Address - Street 1:1072 CASITAS PASS RD
Practice Address - Street 2:# 208
Practice Address - City:CARPINTERIA
Practice Address - State:CA
Practice Address - Zip Code:93013-2109
Practice Address - Country:US
Practice Address - Phone:805-895-5172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-17
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 40526106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA40526OtherMFC LICENSE