Provider Demographics
NPI:1053032383
Name:GONZALEZ, LOURDES Y (MA,BCBA)
Entity type:Individual
Prefix:
First Name:LOURDES
Middle Name:Y
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MA,BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-2834
Mailing Address - Country:US
Mailing Address - Phone:760-565-2702
Mailing Address - Fax:
Practice Address - Street 1:1413 W STATE ST
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-2834
Practice Address - Country:US
Practice Address - Phone:760-565-2702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-22-61114103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1-22-61114OtherBACB CERTIFICATE NUMBER