Provider Demographics
NPI:1710746284
Name:GONZALES, ROGER (LPC-ASSOCIATE)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:LPC-ASSOCIATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11619 WILD THICKET
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254-5005
Mailing Address - Country:US
Mailing Address - Phone:806-282-9833
Mailing Address - Fax:830-310-6313
Practice Address - Street 1:138 OLD SAN ANTONIO RD STE 503
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-3492
Practice Address - Country:US
Practice Address - Phone:210-596-9833
Practice Address - Fax:830-310-6313
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX89142101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health