Provider Demographics
NPI:1073012928
Name:GONZALEZ, MARIO CARLOS
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:CARLOS
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10110 MOUNTAIN LOOP HWY APT 8
Mailing Address - Street 2:
Mailing Address - City:GRANITE FALLS
Mailing Address - State:WA
Mailing Address - Zip Code:98252-9174
Mailing Address - Country:US
Mailing Address - Phone:425-350-5638
Mailing Address - Fax:
Practice Address - Street 1:10710 MUKILTEO SPEEDWAY
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-5021
Practice Address - Country:US
Practice Address - Phone:425-349-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-06
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health