Basic Information
Provider Information | |||||||||
NPI: | 1598801201 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GONZALEZ | ||||||||
FirstName: | CAMILO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 301 GRAND AVE STE 301 | ||||||||
Address2: |   | ||||||||
City: | SOUTH SAN FRANCISCO | ||||||||
State: | CA | ||||||||
PostalCode: | 940803641 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6502440305 | ||||||||
FaxNumber: | 6502441447 | ||||||||
Practice Location | |||||||||
Address1: | 301 GRAND AVE STE 301 | ||||||||
Address2: |   | ||||||||
City: | SOUTH SAN FRANCISCO | ||||||||
State: | CA | ||||||||
PostalCode: | 940803641 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6502440305 | ||||||||
FaxNumber: | 6502441447 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/29/2007 | ||||||||
LastUpdateDate: | 02/25/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | N |   | Other Service Providers | Case Manager/Care Coordinator |   | 101YA0400X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | 99037 | 01 | CA | OLLIN- PROP. 36 | OTHER | 38932 | 01 | CA | AVIVA- MOM | OTHER | 97037 | 01 | CA | OLLIN | OTHER | 38241 | 01 | CA | HORIZONS UNLIMITED | OTHER | 41491 | 01 | CA | ENTRE FAMILIA - OP | OTHER | 38472 | 01 | CA | QUETZAL | OTHER | 38935 | 01 | CA | AVIVA- BABIES | OTHER |