Provider Demographics
NPI:1720838410
Name:GONZALEZ, KENYA I
Entity Type:Individual
Prefix:
First Name:KENYA
Middle Name:I
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 1:1537 SE ELLIOTT AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4807
Mailing Address - Country:US
Mailing Address - Phone:209-417-2976
Mailing Address - Fax:
Practice Address - Street 1:35 NE 197TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-8006
Practice Address - Country:US
Practice Address - Phone:503-473-1876
Practice Address - Fax:877-831-7109
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10224329106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician