Provider Demographics
NPI:1639509417
Name:GONZALEZ PSYCHOLOGICAL SERVICES, P.C.
Entity type:Organization
Organization Name:GONZALEZ PSYCHOLOGICAL SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:503-228-0939
Mailing Address - Street 1:1130 SW MORRISON ST STE 414
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2215
Mailing Address - Country:US
Mailing Address - Phone:503-228-0939
Mailing Address - Fax:503-226-8069
Practice Address - Street 1:1130 SW MORRISON ST STE 414
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2215
Practice Address - Country:US
Practice Address - Phone:503-228-0939
Practice Address - Fax:503-226-8069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-15
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1558103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1558411041Medicare PIN