Provider Demographics
NPI:1407638646
Name:GONZALEZ, AIDAN
Entity Type:Individual
Prefix:
First Name:AIDAN
Middle Name:
Last Name:GONZALEZ
Suffix:
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 1:9153 W 133RD ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66213-4333
Mailing Address - Country:US
Mailing Address - Phone:913-257-5185
Mailing Address - Fax:833-340-7117
Practice Address - Street 1:9153 W 133RD ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66213-4333
Practice Address - Country:US
Practice Address - Phone:913-257-5185
Practice Address - Fax:833-340-7117
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORBT-23-300196106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician