MEDICARE: JOSE LUIS GONZALEZ

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	101YP2500X	Professional Counselor	13392	NC

General Provider Information

NPI Number	:	1811548837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSE LUIS GONZALEZ

Provider Business Mailing Address
First Line	:	2312 SPINDLE TREE DR
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28304-4834
Country	:	US
Telephone Number	:	832-431-7944
Fax Number	:

Provider Business Practice Location Address
First Line	:	1017 HOPE MILLS RD
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28304-4234
Country	:	US
Telephone Number	:	910-491-6011
Fax Number	:

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

Provider Enumeration Date	:	09/20/2019
Last Update Date	:	09/20/2019

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