Provider Demographics
NPI:1740795897
Name:RUFUS GONZALES PSYCHOTHERPAY, LLC
Entity Type:Organization
Organization Name:RUFUS GONZALES PSYCHOTHERPAY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUFUS
Authorized Official - Middle Name:R
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:708-512-4854
Mailing Address - Street 1:6238 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-1202
Mailing Address - Country:US
Mailing Address - Phone:708-512-4854
Mailing Address - Fax:
Practice Address - Street 1:6238 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-1202
Practice Address - Country:US
Practice Address - Phone:708-512-4854
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007450261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health