Provider Demographics
NPI:1023872876
Name:GONZALES, CHRYSTAL G (PPS, LEP)
Entity type:Individual
Prefix:
First Name:CHRYSTAL
Middle Name:G
Last Name:GONZALES
Suffix:
Gender:F
Credentials:PPS, LEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1261 LINCOLN AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-3030
Mailing Address - Country:US
Mailing Address - Phone:408-439-1111
Mailing Address - Fax:
Practice Address - Street 1:1261 LINCOLN AVE STE 104
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-3030
Practice Address - Country:US
Practice Address - Phone:408-439-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA200111511103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool