Provider Demographics
NPI:1306912449
Name:GONZALEZ, GUILLERMO ERNESTO JR (PHD)
Entity type:Individual
Prefix:DR
First Name:GUILLERMO
Middle Name:ERNESTO
Last Name:GONZALEZ
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6826 SPRINGFIELD AVE
Mailing Address - Street 2:STE. 103A
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-2213
Mailing Address - Country:US
Mailing Address - Phone:956-722-3000
Mailing Address - Fax:956-729-1947
Practice Address - Street 1:6826 SPRINGFIELD AVE
Practice Address - Street 2:STE. 103A
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-2213
Practice Address - Country:US
Practice Address - Phone:956-722-3000
Practice Address - Fax:956-729-1947
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2013-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23844103T00000X
TX6198103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0334237-01Medicaid
TXTXB104729Medicare PIN