Healthcare Provider Details

I. General information

NPI: 1477337848
Provider Name (Legal Business Name): SARAH JAQUELYN GONZALEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16830 DUMFRIES RD STE 160
DUMFRIES VA
22025
US

IV. Provider business mailing address

13649 OFFICE PL STE 102
WOODBRIDGE VA
22192-4215
US

V. Phone/Fax

Practice location:
  • Phone: 703-523-1750
  • Fax:
Mailing address:
  • Phone: 703-670-5738
  • Fax: 703-670-8213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904015724
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: