Healthcare Provider Details

I. General information

NPI: 1750717252
Provider Name (Legal Business Name): MS. NINA GABRIELLE GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2013
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 NORTH POINT RD
BALTIMORE MD
21224-3338
US

IV. Provider business mailing address

1204 WALKER AVE
BALTIMORE MD
21239-1740
US

V. Phone/Fax

Practice location:
  • Phone: 443-216-4800
  • Fax: 443-216-4801
Mailing address:
  • Phone: 443-564-6772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number21433
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: