Provider Demographics
NPI:1053437244
Name:GONZALES, DENISE DYANN (PSYD)
Entity type:Individual
Prefix:DR
First Name:DENISE
Middle Name:DYANN
Last Name:GONZALES
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:DENISE
Other - Middle Name:DYANN
Other - Last Name:ROUQUETTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:2095 W VISTA WAY
Mailing Address - Street 2:SUITE #216
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6027
Mailing Address - Country:US
Mailing Address - Phone:760-659-9042
Mailing Address - Fax:760-639-0110
Practice Address - Street 1:2095 W VISTA WAY
Practice Address - Street 2:SUITE #216
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6027
Practice Address - Country:US
Practice Address - Phone:760-659-9042
Practice Address - Fax:760-639-0110
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19182103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical