Provider Demographics
NPI:1902646979
Name:GONZALEZ, MARK RENE
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:RENE
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3904 BLUE JAY DR
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-4882
Mailing Address - Country:US
Mailing Address - Phone:956-451-8246
Mailing Address - Fax:
Practice Address - Street 1:3904 BLUE JAY DR
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-4882
Practice Address - Country:US
Practice Address - Phone:956-451-8246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-28
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35087103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool