Provider Demographics
NPI:1518369735
Name:WINN GONZALES, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:WINN 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 1:2311 PARK AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2104
Mailing Address - Country:US
Mailing Address - Phone:208-878-3350
Mailing Address - Fax:208-878-3351
Practice Address - Street 1:2311 PARK AVE
Practice Address - Street 2:SUITE 8
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2170
Practice Address - Country:US
Practice Address - Phone:208-878-3350
Practice Address - Fax:208-878-3351
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5354101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional