=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144199548
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OCTAVIO LARES GONZALEZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2025
-----------------------------------------------------
Last Update Date | 11/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 309 NEW INDIAN TRAIL CT
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60506-2411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-966-4000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2820 CLINES FORD DR
-----------------------------------------------------
City | BELVIDERE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61008-7129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-319-5660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------