Provider Demographics
NPI:1639665086
Name:GONZALEZ, CYNTHIA ELENA
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ELENA
Last Name:GONZALEZ
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 1:5621 W 104TH ST APT 2A
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-4535
Mailing Address - Country:US
Mailing Address - Phone:773-983-0001
Mailing Address - Fax:
Practice Address - Street 1:306 N KENSINGTON AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526-1870
Practice Address - Country:US
Practice Address - Phone:312-965-2997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst