Provider Demographics
NPI:1740989623
Name:GONZALEZ, LISA MARIE
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
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:PO BOX 351
Mailing Address - Street 2:
Mailing Address - City:MERCEDES
Mailing Address - State:TX
Mailing Address - Zip Code:78570-0351
Mailing Address - Country:US
Mailing Address - Phone:956-532-5318
Mailing Address - Fax:
Practice Address - Street 1:2841 SWR RELAMPAGO DR
Practice Address - Street 2:
Practice Address - City:MERCEDES
Practice Address - State:TX
Practice Address - Zip Code:78570
Practice Address - Country:US
Practice Address - Phone:956-532-5318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX83757101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional