Provider Demographics
NPI:1003195421
Name:GONZALES, MARISELA I
Entity Type:Individual
Prefix:MRS
First Name:MARISELA
Middle Name:
Last Name:GONZALES
Suffix:I
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 1:5575 SIMMONS ST
Mailing Address - Street 2:#1-363
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-9009
Mailing Address - Country:US
Mailing Address - Phone:702-202-2567
Mailing Address - Fax:
Practice Address - Street 1:2535 W CHEYENNE AVE
Practice Address - Street 2:#104
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-8929
Practice Address - Country:US
Practice Address - Phone:702-202-2567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV222Q00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst