Provider Demographics
NPI:1538971775
Name:GONZALES, MADELINE G
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:G
Last Name:GONZALES
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 1:8147 EFFINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-8166
Mailing Address - Country:US
Mailing Address - Phone:901-674-1982
Mailing Address - Fax:
Practice Address - Street 1:6413 QUINCE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-8219
Practice Address - Country:US
Practice Address - Phone:901-690-5213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-24
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23-252303103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst