Basic Information
| Provider Information | |||||||||
| NPI: | 1538591565 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ ESCOBAR | ||||||||
| FirstName: | GAMALIER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RMA (AMT) | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2940 KIMBERLITE CT | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894364103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7754090266 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10038 MEADOW WAY | ||||||||
| Address2: | |||||||||
| City: | TRUCKEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961610482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5304262110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2013 | ||||||||
| LastUpdateDate: | 02/26/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 374700000X | N | Nursing Service Related Providers | Technician | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1538591565 | 05 | NV | MEDICAID |