Provider Demographics
NPI:1164984456
Name:GONZALES LCSW LLC
Entity Type:Organization
Organization Name:GONZALES LCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MORGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:385-434-1274
Mailing Address - Street 1:61 E 1600 N
Mailing Address - Street 2:
Mailing Address - City:GENOLA
Mailing Address - State:UT
Mailing Address - Zip Code:84655-5090
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:61 E 1600 N
Practice Address - Street 2:
Practice Address - City:GENOLA
Practice Address - State:UT
Practice Address - Zip Code:84655-5090
Practice Address - Country:US
Practice Address - Phone:385-434-1274
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-04
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty