Provider Demographics
NPI:1437610086
Name:GONZALEZ, AUDREY (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:WARTSBAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:807 W HIGHWAY 50 STE 3
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1856
Mailing Address - Country:US
Mailing Address - Phone:618-468-8069
Mailing Address - Fax:
Practice Address - Street 1:807 W HIGHWAY 50 STE 3
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1856
Practice Address - Country:US
Practice Address - Phone:618-468-8069
Practice Address - Fax:619-202-2160
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.012116101YP2500X
MO2021046000101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2021046000OtherDEPARTMENT OF PROFESSIONAL REGULATION
IL180.012116OtherDEPARTMENT OF PROFESSIONAL REGULATION