Healthcare Provider Details

I. General information

NPI: 1083550495
Provider Name (Legal Business Name): WILLIAM GONZALEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E DEUCE OF CLUBS STE D
SHOW LOW AZ
85901-4943
US

IV. Provider business mailing address

PO BOX 440
VERNON AZ
85940-0440
US

V. Phone/Fax

Practice location:
  • Phone: 951-834-3406
  • Fax: 951-834-3406
Mailing address:
  • Phone: 951-834-3406
  • Fax: 951-834-3406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MARISSA GONZALEZ
Title or Position: OFFICE MANAGER, CREDENTIALING, BHS
Credential: OM, BHS
Phone: 951-834-3406