Active NPI
Ivan Gonzalez
- Clinical Psychologist
- Fort Bragg, NC
National Provider Identifier
1184013252
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- PSY-004598
- Practice address
- 2817 Reilly Road
Womack Army Medical Center
Fort Bragg, NC 28310 - Phone
- (910) 907-8922
- Fax
- (910) 907-6069
- NPI assigned
- Jan 13, 2015
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | PSY-004598 | AZ | Primary |
Addresses
Primary practice location
2817 Reilly Road
Womack Army Medical Center
Fort Bragg, NC 28310
Mailing address
6600 Van Aalst Blvd
Fort Moore, GA 31905-2102
Phone (706) 545-4237
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PSY-004598 | AZ | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1421107200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1728604800000",
"number": "1184013252",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "6600 VAN AALST BLVD",
"city": "FORT MOORE",
"state": "GA",
"postal_code": "319052102",
"telephone_number": "706-545-4237"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2817 REILLY ROAD",
"address_2": "WOMACK ARMY MEDICAL CENTER",
"city": "FORT BRAGG",
"state": "NC",
"postal_code": "28310",
"telephone_number": "910-907-8922",
"fax_number": "910-907-6069"
}
],
"practiceLocations": [],
"basic": {
"last_name": "GONZALEZ",
"first_name": "IVAN",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2015-01-13",
"last_updated": "2024-10-11",
"certification_date": "2024-10-07",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "AZ",
"license": "PSY-004598",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fort Bragg, NC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 11, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.