MEDICARE: DR. JANICE C GONZALES PHD

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	103TF0200X	Forensic Psychologist	0004196	CO
2	103TC0700X	Clinical Psychologist	PSY4196	CO

General Provider Information

NPI Number	:	1215567425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JANICE C GONZALES PHD

Provider Business Mailing Address
First Line	:	805 DESERT FLOWER BLVD
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81001-1146
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	805 DESERT FLOWER BLVD
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81001-1146
Country	:	US
Telephone Number	:	719-540-2183
Fax Number	:

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

Provider Enumeration Date	:	01/16/2020
Last Update Date	:	08/18/2022

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