Provider Demographics
NPI:1851084404
Name:GONZALES, LUIS GUILLERMO
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:GUILLERMO
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 1:7513 S WALL ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33616-2163
Mailing Address - Country:US
Mailing Address - Phone:850-582-2185
Mailing Address - Fax:
Practice Address - Street 1:7513 S WALL ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33616-2163
Practice Address - Country:US
Practice Address - Phone:850-582-2185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22304101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health