Provider Demographics
NPI:1053932764
Name:GONZALES, ELISA C
Entity type:Individual
Prefix:MS
First Name:ELISA
Middle Name:C
Last Name:GONZALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 E COLLEGE ST APT 7
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-5121
Mailing Address - Country:US
Mailing Address - Phone:505-690-1256
Mailing Address - Fax:
Practice Address - Street 1:527 E COLLEGE ST APT 7
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-5121
Practice Address - Country:US
Practice Address - Phone:505-690-1256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-04
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician