Healthcare Provider Details

I. General information

NPI: 1346101730
Provider Name (Legal Business Name): SAMUEL GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2025
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 FORUM BLVD STE E
COLUMBIA MO
65203-5454
US

IV. Provider business mailing address

3601 W BROADWAY APT 12303
COLUMBIA MO
65203-7911
US

V. Phone/Fax

Practice location:
  • Phone: 573-514-8735
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: