Provider Demographics
NPI:1013146091
Name:GUILLERMO E GONZALEZ JR PHD PC
Entity type:Organization
Organization Name:GUILLERMO E GONZALEZ JR PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GUILLERMO
Authorized Official - Middle Name:E
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHD
Authorized Official - Phone:956-722-3000
Mailing Address - Street 1:6826 SPRINGFIELD AVE
Mailing Address - Street 2:SUITE 103A
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-2213
Mailing Address - Country:US
Mailing Address - Phone:956-722-3000
Mailing Address - Fax:
Practice Address - Street 1:6826 SPRINGFIELD AVE
Practice Address - Street 2:SUITE 103A
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-2213
Practice Address - Country:US
Practice Address - Phone:956-722-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-10
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB104728Medicare PIN