MEDICARE: CAMERON RAY GONZALES MFT-C

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	106H00000X	Marriage & Family Therapist	MFTC.0014443	CO

General Provider Information

NPI Number	:	1366167116
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAMERON RAY GONZALES MFT-C

Provider Business Mailing Address
First Line	:	1942 BROADWAY STE 314C
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80302-5233
Country	:	US
Telephone Number	:	720-767-2229
Fax Number	:

Provider Business Practice Location Address
First Line	:	12211 W ALAMEDA PKWY STE 201
Second Line	:
City	:	LAKEWOOD
State	:	CO
Zip	:	80228-2825
Country	:	US
Telephone Number	:	720-767-2229
Fax Number	:

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

Provider Enumeration Date	:	10/04/2022
Last Update Date	:	05/16/2025

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