Provider Demographics
NPI:1215177209
Name:GONZALEZ, TEAGAN
Entity type:Individual
Prefix:
First Name:TEAGAN
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TEAGAN
Other - Middle Name:
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 959
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98907-0959
Mailing Address - Country:US
Mailing Address - Phone:509-575-4084
Mailing Address - Fax:
Practice Address - Street 1:505 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3547
Practice Address - Country:US
Practice Address - Phone:509-575-4084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-03
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
WA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator