Provider Demographics
NPI:1912549197
Name:GONZALEZ, MARA NAYELLI
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:NAYELLI
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 1:3805 KIMBO RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76111-6210
Mailing Address - Country:US
Mailing Address - Phone:817-966-1300
Mailing Address - Fax:
Practice Address - Street 1:100 CONGRESS AVE STE 2000
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-2745
Practice Address - Country:US
Practice Address - Phone:512-469-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician