Healthcare Provider Details

I. General information

NPI: 1689244485
Provider Name (Legal Business Name): KAITLIN GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6335 JOHN CHAPMAN
SAN ANTONIO TX
78240-7824
US

IV. Provider business mailing address

6335 JOHN CHAPMAN
SAN ANTONIO TX
78240-2285
US

V. Phone/Fax

Practice location:
  • Phone: 210-557-6288
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number71120
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: