Healthcare Provider Details

I. General information

NPI: 1275174617
Provider Name (Legal Business Name): ANISAH GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 W COOLIDGE ST
PHOENIX AZ
85013-2715
US

IV. Provider business mailing address

402 W COOLIDGE ST
PHOENIX AZ
85013-2715
US

V. Phone/Fax

Practice location:
  • Phone: 520-223-5943
  • Fax:
Mailing address:
  • Phone: 520-223-5943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA.BA.70034625
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: