Provider Demographics
NPI:1053856500
Name:GONZALES, MARISA KATHERINE (LPC)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:KATHERINE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 W THUNDERBIRD RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-6248
Mailing Address - Country:US
Mailing Address - Phone:602-638-6661
Mailing Address - Fax:
Practice Address - Street 1:3610 N 44TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-6059
Practice Address - Country:US
Practice Address - Phone:602-638-6661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15736101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional