Provider Demographics
NPI:1437398336
Name:GONZALEZ, TANIA MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:TANIA
Middle Name:MARIE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1350 'E' PACHECO BLVD
Mailing Address - Street 2:PMB #122
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-4946
Mailing Address - Country:US
Mailing Address - Phone:209-631-0373
Mailing Address - Fax:209-722-7210
Practice Address - Street 1:312 W J ST STE 201
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-4073
Practice Address - Country:US
Practice Address - Phone:209-826-4870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-17
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20834103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical