Basic Information
| Provider Information | |||||||||
| NPI: | 1215589163 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALES | ||||||||
| FirstName: | MARIAH | ||||||||
| MiddleName: | GONZALES | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | BCBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 125 PECANWOOD S | ||||||||
| Address2: | |||||||||
| City: | KYLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786405265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3617396824 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1310 W SLAUGHTER LN | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787486556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883083728 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2019 | ||||||||
| LastUpdateDate: | 06/30/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-18-48830 | TX | N | 103K00000X | 1-21-51028 | TX | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.