Provider Demographics
NPI:1295450799
Name:GONZALEZ, VERONICA MARIE (MS)
Entity type:Individual
Prefix:
First Name:VERONICA
Middle Name:MARIE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1369 E 16TH ST # 2
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2008
Mailing Address - Country:US
Mailing Address - Phone:208-878-3423
Mailing Address - Fax:
Practice Address - Street 1:1369 E 16TH ST # 2
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2008
Practice Address - Country:US
Practice Address - Phone:208-734-0407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCOUI-8336101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty