Basic Information
| Provider Information | |||||||||
| NPI: | 1528332178 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MED, BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5554 RESEDA BLVD STE 203 | ||||||||
| Address2: | |||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913566212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187055522 | ||||||||
| FaxNumber: | 8065838064 | ||||||||
| Practice Location | |||||||||
| Address1: | 5554 RESEDA BLVD STE 203 | ||||||||
| Address2: | |||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913566212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187055522 | ||||||||
| FaxNumber: | 8065838064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/29/2012 | ||||||||
| LastUpdateDate: | 08/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-18-33608 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.