Healthcare Provider Details

I. General information

NPI: 1760637730
Provider Name (Legal Business Name): LUIS A. GONZALEZ CASAC-T
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2008
Last Update Date: 11/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NORTH BROADWAY
YONKERS NY
10701
US

IV. Provider business mailing address

317 SOUTH BROADWAY 1ST FLOOR
YONKERS NY
10705
US

V. Phone/Fax

Practice location:
  • Phone: 914-376-7618
  • Fax:
Mailing address:
  • Phone: 914-476-6502
  • Fax: 914-476-2421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20973
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: