Provider Demographics
NPI:1760161343
Name:GONZALES, ISSAC PAUL
Entity Type:Individual
Prefix:
First Name:ISSAC
Middle Name:PAUL
Last Name:GONZALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 N BLACKHORSE DR
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-5020
Mailing Address - Country:US
Mailing Address - Phone:801-200-9256
Mailing Address - Fax:
Practice Address - Street 1:39 N PROFESSIONAL WAY
Practice Address - Street 2:SUITE 4
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-1678
Practice Address - Country:US
Practice Address - Phone:801-980-2566
Practice Address - Fax:801-610-2017
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist