MEDICARE: MARISA BETH GONZALES DNP, APRN, PMHNP-BC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	2024073444	TX

General Provider Information

NPI Number	:	1457187841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISA BETH GONZALES DNP, APRN, PMHNP-BC

Provider Business Mailing Address
First Line	:	8207 MIRAR PASS
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78255-3313
Country	:	US
Telephone Number	:	850-218-4663
Fax Number	:

Provider Business Practice Location Address
First Line	:	8207 MIRAR PASS
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78255-3313
Country	:	US
Telephone Number	:	850-218-4663
Fax Number	:

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

Provider Enumeration Date	:	09/11/2024
Last Update Date	:	09/11/2024

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