Provider Demographics
NPI:1790510378
Name:GONZALEZ GONZALEZ, BERTHA A (LPC-IT)
Entity type:Individual
Prefix:
First Name:BERTHA
Middle Name:A
Last Name:GONZALEZ GONZALEZ
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 FORWARD DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-2443
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:815 FORWARD DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-2443
Practice Address - Country:US
Practice Address - Phone:608-268-6530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-04
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8228226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health