Provider Demographics
NPI:1679827356
Name:GONZALES, DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:GONZALES
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 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:CR 115
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-1660
Mailing Address - Fax:503-494-5407
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:CR 115
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-1660
Practice Address - Fax:503-494-5407
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-02
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1066101YP2500X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC1066OtherSTATE OF OREGON BOARD OF LICENSED PROFESSIONAL COUNSELORS AND THERAPISTS