MEDICARE: LISA J GONZALEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	091838-1	NY

General Provider Information

NPI Number	:	1386019354
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA J GONZALEZ

Provider Business Mailing Address
First Line	:	4842 44TH ST APT 2F
Second Line	:
City	:	WOODSIDE
State	:	NY
Zip	:	11377-6917
Country	:	US
Telephone Number	:	646-624-9575
Fax Number	:

Provider Business Practice Location Address
First Line	:	119 SCHENECTADY AVE FL 3
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11213-2330
Country	:	US
Telephone Number	:	347-915-1112
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2015
Last Update Date	:	09/16/2020

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