Basic Information
| Provider Information | |||||||||
| NPI: | 1699154377 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | BARBARA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | QMHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11695 SW TEAL BLVD APT B | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970078081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037173231 | ||||||||
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| Practice Location | |||||||||
| Address1: | 65 N HIGHWAY 101 STE 204 | ||||||||
| Address2: | |||||||||
| City: | WARRENTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033250241 | ||||||||
| FaxNumber: | 5038612043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2015 | ||||||||
| LastUpdateDate: | 04/08/2019 | ||||||||
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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 | 101YM0800X | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 500690706 | 05 | OR | MEDICAID |