Provider Demographics
NPI:1871143065
Name:GONZALES, LISA MARIE (LCDC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 W COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-3611
Mailing Address - Country:US
Mailing Address - Phone:210-434-0531
Mailing Address - Fax:210-434-0321
Practice Address - Street 1:3701 W COMMERCE ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3611
Practice Address - Country:US
Practice Address - Phone:210-434-0531
Practice Address - Fax:210-434-0321
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14502101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX14548732Medicaid