Provider Demographics
NPI:1992135743
Name:GONZALES, BRITTANY
Entity type:Individual
Prefix:
First Name:BRITTANY
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRITTANY
Other - Middle Name:
Other - Last Name:KASEFANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:849 E FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1806
Mailing Address - Country:US
Mailing Address - Phone:208-907-1708
Mailing Address - Fax:208-939-9009
Practice Address - Street 1:849 E FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1806
Practice Address - Country:US
Practice Address - Phone:208-907-1708
Practice Address - Fax:208-939-9009
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-14
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMFT-6020101Y00000X, 106H00000X
IDLAMFT-5411106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty