Provider Demographics
NPI:1396397196
Name:GONZALEZ, VICTOR R JR
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:R
Last Name:GONZALEZ
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-5846
Mailing Address - Country:US
Mailing Address - Phone:405-564-3408
Mailing Address - Fax:
Practice Address - Street 1:1209 S MAIN ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-5846
Practice Address - Country:US
Practice Address - Phone:405-564-3408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician