Provider Demographics
NPI:1144199548
Name:LARES GONZALEZ, OCTAVIO
Entity type:Individual
Prefix:
First Name:OCTAVIO
Middle Name:
Last Name:LARES 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 1:2820 CLINES FORD DR
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-7129
Mailing Address - Country:US
Mailing Address - Phone:815-319-5660
Mailing Address - Fax:
Practice Address - Street 1:309 NEW INDIAN TRAIL CT
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-2411
Practice Address - Country:US
Practice Address - Phone:630-966-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-03
Last Update Date:2025-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health