MEDICARE: MARJORIE GONZALEZ LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	114080	MA

General Provider Information

NPI Number	:	1194122143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARJORIE GONZALEZ LICSW

Provider Business Mailing Address
First Line	:	57 E MAIN ST STE 200
Second Line	:
City	:	WESTBOROUGH
State	:	MA
Zip	:	01581-1457
Country	:	US
Telephone Number	:	508-366-0406
Fax Number	:

Provider Business Practice Location Address
First Line	:	57 E MAIN ST STE 200
Second Line	:
City	:	WESTBOROUGH
State	:	MA
Zip	:	01581-1457
Country	:	US
Telephone Number	:	508-366-0406
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/19/2014
Last Update Date	:	11/19/2014

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