Provider Demographics
NPI:1578383105
Name:WILSON GONZALEZ, STEPHANIE ERIN
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ERIN
Last Name:WILSON GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15519 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-4525
Mailing Address - Country:US
Mailing Address - Phone:310-679-9126
Mailing Address - Fax:
Practice Address - Street 1:BHS
Practice Address - Street 2:15519 SOUTH CRENSHAW BOULEVARD
Practice Address - City:GARDENIA
Practice Address - State:CA
Practice Address - Zip Code:90249
Practice Address - Country:US
Practice Address - Phone:310-679-9126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24976101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty