Healthcare Provider Details

I. General information

NPI: 1619662269
Provider Name (Legal Business Name): MARCUS ANTHONY GONZALES RBT-23-266695
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 08/25/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5210 THOUSAND OAKS DR
SAN ANTONIO TX
78233-6974
US

IV. Provider business mailing address

5210 THOUSAND OAKS DR # 1301
SAN ANTONIO TX
78233-6974
US

V. Phone/Fax

Practice location:
  • Phone: 737-242-7925
  • Fax: 726-204-8637
Mailing address:
  • Phone: 726-215-6448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-266695
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: