Provider Demographics
NPI:1871607705
Name:GONZALES, JAMES L (PHD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:L
Last Name:GONZALES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5435 SUGARLOAF PKWY
Mailing Address - Street 2:SUITE 1103
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7831
Mailing Address - Country:US
Mailing Address - Phone:770-995-6026
Mailing Address - Fax:
Practice Address - Street 1:5435 SUGARLOAF PKWY
Practice Address - Street 2:SUITE 1103
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-7831
Practice Address - Country:US
Practice Address - Phone:770-995-6026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1640103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00264939OtherRAILROAD
GA00817275AMedicaid
GA027535OtherBLUE CROSS BLUE SHIELD
GAP00264939OtherRAILROAD