Provider Demographics
NPI:1225769607
Name:GONZALEZ, IRENE JAZIL (SUDPT)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:JAZIL
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98930-1009
Mailing Address - Country:US
Mailing Address - Phone:150-940-2909
Mailing Address - Fax:866-974-8679
Practice Address - Street 1:106 N ELM ST
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:WA
Practice Address - Zip Code:98930-1009
Practice Address - Country:US
Practice Address - Phone:509-402-9090
Practice Address - Fax:866-974-8679
Is Sole Proprietor?:No
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61241782101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)