Provider Demographics
NPI:1013540541
Name:GONZALES, BRIANNA LEIGH
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:LEIGH
Last Name:GONZALES
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 1:165 PILGRIM RD APT SUITE
Mailing Address - Street 2:APT, SUITE, BLDG. (OPTIONAL)
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79602-4355
Mailing Address - Country:US
Mailing Address - Phone:325-238-1060
Mailing Address - Fax:
Practice Address - Street 1:4606 S 14TH ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79605-4735
Practice Address - Country:US
Practice Address - Phone:325-704-4392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician