Provider Demographics
NPI:1376189399
Name:GONZALES, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 W LINCOLN ST # 119
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78552-5921
Mailing Address - Country:US
Mailing Address - Phone:956-367-3265
Mailing Address - Fax:
Practice Address - Street 1:722 MORGAN BLVD STE B
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-5124
Practice Address - Country:US
Practice Address - Phone:956-230-2044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-25
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX82129101YM0800X
TX14102101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health