Provider Demographics
NPI:1225389471
Name:GONZALEZ, DEIRDRE (MASTERS DEGREE(SE))
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MASTERS DEGREE(SE)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 E 143RD ST APT 10D
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10454-1206
Mailing Address - Country:US
Mailing Address - Phone:917-703-2726
Mailing Address - Fax:
Practice Address - Street 1:350 E 143RD ST APT 10D
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10454-1206
Practice Address - Country:US
Practice Address - Phone:917-703-2726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1380949174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist