Provider Demographics
NPI:1760836233
Name:GONZALES, HEATHER (CADCI)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:CADCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 SULLIVAN LN
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89431-2815
Mailing Address - Country:US
Mailing Address - Phone:775-355-7734
Mailing Address - Fax:
Practice Address - Street 1:1755 SULLIVAN LN
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-2815
Practice Address - Country:US
Practice Address - Phone:775-355-7734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV01014101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1922056415Medicaid