Healthcare Provider Details

I. General information

NPI: 1235644691
Provider Name (Legal Business Name): CERESA GONZALEZ LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2017
Last Update Date: 12/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 SCHIEFFELIN AVE
BRONX NY
10466-5605
US

IV. Provider business mailing address

750 TILDEN ST
BRONX NY
10467-6013
US

V. Phone/Fax

Practice location:
  • Phone: 718-231-3400
  • Fax:
Mailing address:
  • Phone: 718-231-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number102526
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: