Healthcare Provider Details

I. General information

NPI: 1780593418
Provider Name (Legal Business Name): NICOLAS DAVID GONZALES II CBT.CB.70165722
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 N SULLIVAN RD STE F 139
SPOKANE WA
99037-8543
US

IV. Provider business mailing address

PO BOX 988
PULLMAN WA
99163-0988
US

V. Phone/Fax

Practice location:
  • Phone: 509-200-6976
  • Fax: 772-675-9100
Mailing address:
  • Phone: 509-200-6976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberCBT.CB.70165722
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: