Provider Demographics
NPI:1770612871
Name:GONZALES, FRED (LBSW)
Entity type:Individual
Prefix:MR
First Name:FRED
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9311 REGIMENT DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-2866
Mailing Address - Country:US
Mailing Address - Phone:210-691-3244
Mailing Address - Fax:
Practice Address - Street 1:1500 S ZARZAMORA ST STE 135
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-7224
Practice Address - Country:US
Practice Address - Phone:210-223-4066
Practice Address - Fax:210-223-9377
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33688104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker