Provider Demographics
NPI:1114695855
Name:GONZALEZ, THEODORUS ANTONIO
Entity type:Individual
Prefix:
First Name:THEODORUS
Middle Name:ANTONIO
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TONY
Other - Middle Name:A
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4856 INNOVATION DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5539
Mailing Address - Country:US
Mailing Address - Phone:970-494-4200
Mailing Address - Fax:844-270-1824
Practice Address - Street 1:221 E 29TH ST STE 101
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-2746
Practice Address - Country:US
Practice Address - Phone:970-494-4200
Practice Address - Fax:844-270-1824
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0023635101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional