Provider Demographics
NPI:1962395764
Name:GONZALEZ, SERGIO A
Entity type:Individual
Prefix:
First Name:SERGIO
Middle Name:A
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 1:2664 N BUFFALO DR UNIT 2213
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-4900
Mailing Address - Country:US
Mailing Address - Phone:805-409-6434
Mailing Address - Fax:
Practice Address - Street 1:2820 W CHARLESTON BLVD STE 17
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1930
Practice Address - Country:US
Practice Address - Phone:702-781-3274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-30
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT-25-439488106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician