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General NPI Number Information
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NPI Number | 1114695855
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Entity Type | Individual
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Provider Name | THEODORUS ANTONIO GONZALEZ
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Gender | Male
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Dates
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Enumeration Date | 08/30/2021
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Last Update Date | 07/29/2025
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Provider Practice Location Address
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Address Line | 221 E 29TH ST STE 101
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City | LOVELAND
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State | CO
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Zip | 80538-2746
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Country | US
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Telephone | 970-494-4200
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Fax | 844-270-1824
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Provider Business Mailing Address
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Address Line | 4856 INNOVATION DR
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City | FORT COLLINS
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State | CO
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Zip | 80525-5539
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Country | US
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Telephone | 970-494-4200
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Fax | 844-270-1824
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPCC.0023635
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License Number State | CO
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