Provider Demographics
NPI:1316436959
Name:GONZALES, OLIVIA (LMFTA)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1960 N HOLY NAMES CT
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99224-5803
Mailing Address - Country:US
Mailing Address - Phone:509-455-4968
Mailing Address - Fax:509-455-4988
Practice Address - Street 1:1960 N HOLY NAMES CT
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99224-5803
Practice Address - Country:US
Practice Address - Phone:509-455-4968
Practice Address - Fax:509-455-4988
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
WA60956978106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2139223Medicaid