Provider Demographics
NPI:1619099793
Name:GONZALEZ, TERESA (MA)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 PAPAGO BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AZ
Mailing Address - Zip Code:86047-2021
Mailing Address - Country:US
Mailing Address - Phone:928-386-0450
Mailing Address - Fax:
Practice Address - Street 1:125 PAPAGO BLVD
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-2021
Practice Address - Country:US
Practice Address - Phone:928-386-0450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6867477385HR2055X
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child