Healthcare Provider Details

I. General information

NPI: 1629888094
Provider Name (Legal Business Name): GLISSETTE GONZALEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GLISSETTE SERRANO RODRIGUEZ LCSW

II. Dates (important events)

Enumeration Date: 01/08/2025
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10634 BAHAMA WOODSTAR CT
RIVERVIEW FL
33579-3524
US

IV. Provider business mailing address

2995 DREW ST
CLEARWATER FL
33759-3012
US

V. Phone/Fax

Practice location:
  • Phone: 813-816-1445
  • Fax:
Mailing address:
  • Phone: 727-281-9065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number23502
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: