Provider Demographics
NPI:1154160158
Name:GONZALEZ, MARISA
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10001 S 1ST ST APT 1334
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-6850
Mailing Address - Country:US
Mailing Address - Phone:806-500-9133
Mailing Address - Fax:
Practice Address - Street 1:10001 S 1ST ST APT 1334
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-6850
Practice Address - Country:US
Practice Address - Phone:806-500-9133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-21
Last Update Date:2025-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX205517106H00000X
PAAMF000003106H00000X
WAMG61663578106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist