MEDICARE: RODOLFO GONZALEZ LCSW

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
2	1041C0700X	Clinical Social Worker	0904010867	VA

General Provider Information

NPI Number	:	1487294526
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RODOLFO GONZALEZ LCSW

Provider Business Mailing Address
First Line	:	5537 RIDGETON HILL CT
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22032-4039
Country	:	US
Telephone Number	:	703-895-9696
Fax Number	:

Provider Business Practice Location Address
First Line	:	5537 RIDGETON HILL CT
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22032-4039
Country	:	US
Telephone Number	:	703-895-9696
Fax Number	:

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

Provider Enumeration Date	:	01/07/2020
Last Update Date	:	03/10/2023

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