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General NPI Number Information
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NPI Number | 1730764176
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Entity Type | Individual
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Provider Name | MR. KEGAN GONZALEZ
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Gender | Male
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Dates
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Enumeration Date | 03/17/2021
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Last Update Date | 03/17/2021
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Provider Practice Location Address
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Address Line | 1310 W SLAUGHTER LN
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City | AUSTIN
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State | TX
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Zip | 78748-6556
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Country | US
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Telephone | 832-541-4119
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Fax |
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Provider Business Mailing Address
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Address Line | 6011 FAIRWAY ST UNIT A
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City | AUSTIN
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State | TX
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Zip | 78741-3445
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Country | US
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Telephone | 832-541-4119
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Fax |
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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 | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | RBT-20-125537
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License Number State | TX
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