Provider Demographics
NPI:1689861387
Name:GONZALEZ, VICTOR JR (PSYD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:
Last Name:GONZALEZ
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 CLUB HOUSE DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-2473
Mailing Address - Country:US
Mailing Address - Phone:404-245-7143
Mailing Address - Fax:
Practice Address - Street 1:3380 TRICKUM RD
Practice Address - Street 2:BUILDING 1000, SUITE 102
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3680
Practice Address - Country:US
Practice Address - Phone:770-924-9700
Practice Address - Fax:770-926-0690
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-27
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002448103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000913646AMedicaid