Provider Demographics
NPI:1811936206
Name:GONZALES, DANIEL SULLIVAN (PHD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:SULLIVAN
Last Name:GONZALES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 N MAIN ST
Mailing Address - Street 2:SUITE C1
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144
Mailing Address - Country:US
Mailing Address - Phone:704-636-9550
Mailing Address - Fax:704-636-5865
Practice Address - Street 1:417 N MAIN ST
Practice Address - Street 2:SUITE C1
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144
Practice Address - Country:US
Practice Address - Phone:704-636-9550
Practice Address - Fax:704-636-5865
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1579103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6888408Medicaid
NC6888408Medicaid