Healthcare Provider Details

I. General information

NPI: 1457447963
Provider Name (Legal Business Name): IRAIDA GONZALEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 CHALKSTONE AVE
PROVIDENCE RI
02908-4728
US

IV. Provider business mailing address

825 CHALKSTONE AVE
PROVIDENCE RI
02908-4728
US

V. Phone/Fax

Practice location:
  • Phone: 401-456-4807
  • Fax:
Mailing address:
  • Phone: 401-456-4807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW01669
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number3030637
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: