Healthcare Provider Details

I. General information

NPI: 1750104568
Provider Name (Legal Business Name): ISAIAH XAVIER GONZALEZ LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2024
Last Update Date: 12/31/2024
Certification Date: 12/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N 16TH AVE
PHOENIX AZ
85007-2443
US

IV. Provider business mailing address

3955 W READE AVE
PHOENIX AZ
85019-2895
US

V. Phone/Fax

Practice location:
  • Phone: 480-267-0320
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-22462
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: