Provider Demographics
NPI:1144801671
Name:GONZALEZ, GEMIMA FOGACA
Entity Type:Individual
Prefix:MRS
First Name:GEMIMA
Middle Name:FOGACA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 TYLER ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-3241
Mailing Address - Country:US
Mailing Address - Phone:339-216-7211
Mailing Address - Fax:
Practice Address - Street 1:12 TYLER ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-3241
Practice Address - Country:US
Practice Address - Phone:339-216-7211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker