Provider Demographics
NPI:1043234453
Name:GONZALES, ELIZABETH (CPED)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:CPED
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPED
Mailing Address - Street 1:417 STORRS RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-1200
Mailing Address - Country:US
Mailing Address - Phone:860-450-1689
Mailing Address - Fax:
Practice Address - Street 1:417 STORRS RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD CENTER
Practice Address - State:CT
Practice Address - Zip Code:06250-1200
Practice Address - Country:US
Practice Address - Phone:860-456-2150
Practice Address - Fax:860-456-2150
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2253235-001174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4999580001Medicare NSC