MEDICARE: DR. VERA A GONZALES PH.D.

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	103T00000X	Psychologist	31408	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00000011GT	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1861579187
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VERA A GONZALES PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 1665
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77574-1665
Country	:	US
Telephone Number	:	713-922-4850
Fax Number	:	713-583-5282

Provider Business Practice Location Address
First Line	:	14100 SOUTHWEST FWY
Second Line	:	360
City	:	SUGAR LAND
State	:	TX
Zip	:	77478-3466
Country	:	US
Telephone Number	:	713-922-4850
Fax Number	:	713-583-5282

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

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	04/27/2010

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