MEDICARE: IGNACIO FABIAN GONZALES MS

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	101YM0800X	Mental Health Counselor	RC00054597	WA
2	101YM0800X	Mental Health Counselor	LH60063586	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093742595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IGNACIO FABIAN GONZALES MS

Provider Business Mailing Address
First Line	:	660 S COOLIDGE ST
Second Line	:
City	:	MOSES LAKE
State	:	WA
Zip	:	98837-1872
Country	:	US
Telephone Number	:	509-793-9715
Fax Number	:	509-764-3244

Provider Business Practice Location Address
First Line	:	1550 S PIONEER WAY STE 165
Second Line	:
City	:	MOSES LAKE
State	:	WA
Zip	:	98837-4637
Country	:	US
Telephone Number	:	509-793-9780
Fax Number	:	509-764-3246

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

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	04/27/2021

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