Healthcare Provider Details

I. General information

NPI: 1659285930
Provider Name (Legal Business Name): SUSAN GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 YAUGER WAY SW
OLYMPIA WA
98502-8660
US

IV. Provider business mailing address

2636 18TH AVE NE
OLYMPIA WA
98506-3514
US

V. Phone/Fax

Practice location:
  • Phone: 360-878-8248
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: