Provider Demographics
NPI:1275808487
Name:JAMES L. GONZALES COUNSELING & PSYCHOLOGICAL SERVICES PC
Entity Type:Organization
Organization Name:JAMES L. GONZALES COUNSELING & PSYCHOLOGICAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:770-995-6026
Mailing Address - Street 1:5435 SUGARLOAF PKWY
Mailing Address - Street 2:SUITE 1103
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5700
Mailing Address - Country:US
Mailing Address - Phone:770-995-6026
Mailing Address - Fax:770-995-6084
Practice Address - Street 1:5435 SUGARLOAF PKWY
Practice Address - Street 2:SUITE 1103
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5700
Practice Address - Country:US
Practice Address - Phone:770-995-6026
Practice Address - Fax:770-995-6084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1640261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00264939OtherRAILROAD
GA027535OtherBLUE CROSS BLUE SHIELD
GA00817275AMedicaid
GAP00264939OtherRAILROAD