Provider Demographics
NPI:1689181810
Name:GONZALEZ, DEYANIRA (MSW)
Entity Type:Individual
Prefix:MRS
First Name:DEYANIRA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MRS
Other - First Name:DEYANIRA
Other - Middle Name:
Other - Last Name:VALDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:1515 E COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-1846
Mailing Address - Country:US
Mailing Address - Phone:509-488-5256
Mailing Address - Fax:509-488-9939
Practice Address - Street 1:1515 E COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-1846
Practice Address - Country:US
Practice Address - Phone:509-488-5256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-09
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60784966101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2100261Medicaid