Provider Demographics
NPI:1447549696
Name:GONZALEZ, MARCOS MANUEL
Entity type:Individual
Prefix:
First Name:MARCOS
Middle Name:MANUEL
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARCOS
Other - Middle Name:
Other - Last Name:TAMAYO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1690 W SHAW AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3519
Mailing Address - Country:US
Mailing Address - Phone:855-343-1057
Mailing Address - Fax:
Practice Address - Street 1:1690 W SHAW AVE STE 201
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3519
Practice Address - Country:US
Practice Address - Phone:855-343-1057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-28
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85082106H00000X
CA116847106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist