=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366167116
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAMERON RAY GONZALES MFT-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2022
-----------------------------------------------------
Last Update Date | 05/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12211 W ALAMEDA PKWY STE 201
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80228-2825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-767-2229
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1942 BROADWAY STE 314C
-----------------------------------------------------
City | BOULDER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80302-5233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-767-2229
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFTC.0014443
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------