Basic Information
| Provider Information | |||||||||
| NPI: | 1801973367 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | CONSTANCE | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NAST | ||||||||
| OtherFirstName: | CONNIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | M.ED.,LCPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1801 FOX DR | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618207236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173988080 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1801 FOX DR | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618207236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173988080 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | IL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.