Healthcare Provider Details

I. General information

NPI: 1821700667
Provider Name (Legal Business Name): RUBEN CARLOS GONZALEZ LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2022
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 ARBOR ST
VANDENBRG AFB CA
93437-1304
US

IV. Provider business mailing address

8134 OLD KEENE MILL RD
SPRINGFIELD VA
22152-1800
US

V. Phone/Fax

Practice location:
  • Phone: 323-359-9125
  • Fax:
Mailing address:
  • Phone: 703-569-8731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701012071
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: