Healthcare Provider Details

I. General information

NPI: 1255014247
Provider Name (Legal Business Name): MR. LUIS ENRIQUE GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 LOMBARD ST
NEW HAVEN CT
06513-2910
US

IV. Provider business mailing address

11 TURTLE CREEK LN APT B27
EAST HARTFORD CT
06108-2342
US

V. Phone/Fax

Practice location:
  • Phone: 203-874-6270
  • Fax:
Mailing address:
  • Phone: 959-200-2133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: