Healthcare Provider Details

I. General information

NPI: 1295450799
Provider Name (Legal Business Name): VERONICA MARIE GONZALEZ MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2022
Last Update Date: 10/06/2022
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1369 E 16TH ST # 2
BURLEY ID
83318-2008
US

IV. Provider business mailing address

1369 E 16TH ST # 2
BURLEY ID
83318-2008
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-0407
  • Fax:
Mailing address:
  • Phone: 208-878-3423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCOUI-8336
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: