MEDICARE: MRS. DEBORAH MARIE GONZALES LCSW

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	1041C0700X	Clinical Social Worker	C000671	NC
2	1041C0700X	Clinical Social Worker	841	AK

General Provider Information

NPI Number	:	1689667024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DEBORAH MARIE GONZALES LCSW

Provider Business Mailing Address
First Line	:	PO BOX 772244
Second Line	:
City	:	EAGLE RIVER
State	:	AK
Zip	:	99577-2244
Country	:	US
Telephone Number	:	907-694-7031
Fax Number	:	907-745-1185

Provider Business Practice Location Address
First Line	:	11517 OLD GLENN HWY
Second Line	:	SUITE # 203
City	:	EAGLE RIVER
State	:	AK
Zip	:	99577-7312
Country	:	US
Telephone Number	:	907-694-7031
Fax Number	:	907-745-1185

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

Provider Enumeration Date	:	08/30/2005
Last Update Date	:	10/09/2008

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