Provider Demographics
NPI:1396018222
Name:GONZALEZ, MARIANA
Entity Type:Individual
Prefix:
First Name:MARIANA
Middle Name:
Last Name:GONZALEZ
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 1:1900 SHINER DR
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-4757
Mailing Address - Country:US
Mailing Address - Phone:972-567-5053
Mailing Address - Fax:
Practice Address - Street 1:4225 OFFICE PKWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-3628
Practice Address - Country:US
Practice Address - Phone:214-821-6505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080579802Medicaid