Provider Demographics
NPI:1326463027
Name:GONZALEZ, MARIE I (LCSW)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:I
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4485 TENCH ROAD
Mailing Address - Street 2:SUITE 1221
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024
Mailing Address - Country:US
Mailing Address - Phone:678-862-3024
Mailing Address - Fax:
Practice Address - Street 1:4485 TENCH RD
Practice Address - Street 2:SUITE 1221
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6739
Practice Address - Country:US
Practice Address - Phone:678-862-3024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW004997101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health