Provider Demographics
NPI:1871868976
Name:GONZALES, JOHNNY DEAN (BS)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:DEAN
Last Name:GONZALES
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10180 SE SUNNYSIDE RD
Mailing Address - Street 2:1ST FLOOR, WING A
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-8970
Mailing Address - Country:US
Mailing Address - Phone:503-571-0884
Mailing Address - Fax:503-571-0866
Practice Address - Street 1:10180 SE SUNNYSIDE RD
Practice Address - Street 2:1ST FLOOR, WING A
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8970
Practice Address - Country:US
Practice Address - Phone:503-571-0884
Practice Address - Fax:503-571-0866
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR103TA0400X101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)