Provider Demographics
NPI:1588021307
Name:GONZALEZ, DAVID ANDRES (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ANDRES
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 W HARRISON ST STE 755
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3863
Mailing Address - Country:US
Mailing Address - Phone:312-563-2024
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST STE 755
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3863
Practice Address - Country:US
Practice Address - Phone:312-563-2024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-25
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37041103G00000X, 103TC0700X
IL07101680103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX360215301Medicaid
TX360215302OtherCSHCN
TX360215301Medicaid