Provider Demographics
NPI:1215589163
Name:GONZALES, MARIAH GONZALES (BCBA)
Entity Type:Individual
Prefix:MISS
First Name:MARIAH
Middle Name:GONZALES
Last Name:GONZALES
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 PECANWOOD S
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-5265
Mailing Address - Country:US
Mailing Address - Phone:361-739-6824
Mailing Address - Fax:
Practice Address - Street 1:1310 W SLAUGHTER LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-6556
Practice Address - Country:US
Practice Address - Phone:888-308-3728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-18-48830106S00000X
TX1-21-51028103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician