Basic Information
| Provider Information | |||||||||
| NPI: | 1134213556 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | OLIVIA | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 MARK DR. | ||||||||
| Address2: | |||||||||
| City: | GERING | ||||||||
| State: | NE | ||||||||
| PostalCode: | 69341 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4110 AVE D | ||||||||
| Address2: | |||||||||
| City: | SCOTTSBLUFF | ||||||||
| State: | NE | ||||||||
| PostalCode: | 69361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3086353171 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 50 | NE | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.