Provider Demographics
NPI:1821676073
Name:GONZALES, CAROL GRACE (PHD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:GRACE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHILDRENS PL
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1081
Mailing Address - Country:US
Mailing Address - Phone:314-454-6069
Mailing Address - Fax:314-454-4013
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1081
Practice Address - Country:US
Practice Address - Phone:314-454-6069
Practice Address - Fax:314-454-4013
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023001483103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist