Healthcare Provider Details

I. General information

NPI: 1215255492
Provider Name (Legal Business Name): JAIME LUIS GONZALEZ MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 05/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 BO PALO ALTO
MANATI PR
00674-6903
US

IV. Provider business mailing address

PO BOX 207
MANATI PR
00674-0207
US

V. Phone/Fax

Practice location:
  • Phone: 787-317-9786
  • Fax: 787-780-1674
Mailing address:
  • Phone: 787-317-9786
  • Fax: 787-780-1674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2190
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: