Basic Information
Provider Information | |||||||||
NPI: | 1043533979 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GONZALEZ | ||||||||
FirstName: | LUIS | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | SUBSTANCE ABUSE COUN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 501 | ||||||||
Address2: |   | ||||||||
City: | BROOKLYN | ||||||||
State: | CT | ||||||||
PostalCode: | 062340501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8605760890 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 45 WADSWORTH ST | ||||||||
Address2: |   | ||||||||
City: | HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 061067108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8605271124 | ||||||||
FaxNumber: | 8607242539 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/06/2010 | ||||||||
LastUpdateDate: | 05/13/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.