Provider Demographics
NPI:1124192281
Name:GONZALES, TWAIN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TWAIN
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940-1941
Mailing Address - Country:US
Mailing Address - Phone:302-430-9997
Mailing Address - Fax:302-644-4909
Practice Address - Street 1:219 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-1941
Practice Address - Country:US
Practice Address - Phone:302-430-9997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB1-0000865103TC0700X
FLPY8532103TC0700X
PAPS005925L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000030388Medicaid