Basic Information
| Provider Information | |||||||||
| NPI: | 1750486569 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44 BIRCHWOOD HEIGHTS | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606666951 | ||||||||
| FaxNumber: | 8606676799 | ||||||||
| Practice Location | |||||||||
| Address1: | VAMC 555 WILLARD AVE. | ||||||||
| Address2: | |||||||||
| City: | NEWINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606666951 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 002361 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.