Provider Demographics
NPI:1740619782
Name:GONZALEZ, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
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:PO BOX 523
Mailing Address - Street 2:
Mailing Address - City:DONALD
Mailing Address - State:OR
Mailing Address - Zip Code:97020-0523
Mailing Address - Country:US
Mailing Address - Phone:541-217-1600
Mailing Address - Fax:503-361-2664
Practice Address - Street 1:3180 CENTER ST NE STE 3360
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301
Practice Address - Country:US
Practice Address - Phone:503-588-5351
Practice Address - Fax:503-361-2664
Is Sole Proprietor?:No
Enumeration Date:2013-11-08
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORL78831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health