Provider Demographics
NPI:1881964666
Name:GONZALEZ, CLARISSA ANDREA (SLP-INTERN)
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:ANDREA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:SLP-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13642 N HIGHWAY 183 STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-2210
Mailing Address - Country:US
Mailing Address - Phone:512-331-4115
Mailing Address - Fax:
Practice Address - Street 1:13642 N HIGHWAY 183 STE 200
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-2210
Practice Address - Country:US
Practice Address - Phone:512-331-4115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-10
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118927235Z00000X
TX36677235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207164901Medicaid
TX149984001Medicaid
TX149984001Medicaid
TX207164901Medicaid