MEDICARE: MARISA KATHERINE GONZALES LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	15736	AZ

General Provider Information

NPI Number	:	1053856500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISA KATHERINE GONZALES LPC

Provider Business Mailing Address
First Line	:	128 W THUNDERBIRD RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85023-6248
Country	:	US
Telephone Number	:	602-638-6661
Fax Number	:

Provider Business Practice Location Address
First Line	:	3610 N 44TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85018-6059
Country	:	US
Telephone Number	:	602-638-6661
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2016
Last Update Date	:	12/19/2016

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