Provider Demographics
NPI:1336293463
Name:GONZALEZ, LETICIA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LETICIA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 E 40TH ST
Mailing Address - Street 2:APT. #2
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-4817
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:655 E JERSEY ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07206-1259
Practice Address - Country:US
Practice Address - Phone:908-994-7223
Practice Address - Fax:908-994-7354
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC053943001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0021806Medicaid
NJBA526562Medicare ID - Type Unspecified