Provider Demographics
NPI:1700057130
Name:GONZALES, MARK (LPC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3035 NW 63RD ST
Mailing Address - Street 2:230
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-3632
Mailing Address - Country:US
Mailing Address - Phone:405-242-5342
Mailing Address - Fax:405-529-6972
Practice Address - Street 1:3035 NW 63RD ST
Practice Address - Street 2:230
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-3632
Practice Address - Country:US
Practice Address - Phone:405-242-5342
Practice Address - Fax:405-529-6972
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-13
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2458101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200305510AMedicaid