MEDICARE: MR. MARCIAL ANTHONY GONZALEZ M.S ED., CAS, BCBA

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	103K00000X	Behavior Analyst	1119578	VA

General Provider Information

NPI Number	:	1154691889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARCIAL ANTHONY GONZALEZ M.S ED., CAS, BCBA

Provider Business Mailing Address
First Line	:	5500 PORT HUDSON CT
Second Line	:
City	:	VIRGINIA BCH
State	:	VA
Zip	:	23464-8781
Country	:	US
Telephone Number	:	757-724-8346
Fax Number	:

Provider Business Practice Location Address
First Line	:	5500 PORT HUDSON CT
Second Line	:
City	:	VIRGINIA BCH
State	:	VA
Zip	:	23464-8781
Country	:	US
Telephone Number	:	757-724-8346
Fax Number	:

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

Provider Enumeration Date	:	01/11/2012
Last Update Date	:	01/11/2012

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