Healthcare Provider Details

I. General information

NPI: 1740668045
Provider Name (Legal Business Name): MARCIA A GONZALES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2015
Last Update Date: 05/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 THOMPSON AVE
EAST HAVEN CT
06512-2934
US

IV. Provider business mailing address

145 UNION ST
GUILFORD CT
06437-2718
US

V. Phone/Fax

Practice location:
  • Phone: 203-468-3297
  • Fax: 203-468-3334
Mailing address:
  • Phone: 203-530-4957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number004730
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: