Provider Demographics
NPI:1346373206
Name:GONZALEZ, LISA (MS, LCDP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MS, LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19801-1114
Mailing Address - Country:US
Mailing Address - Phone:302-320-2100
Mailing Address - Fax:302-320-2121
Practice Address - Street 1:501 W 14TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-1013
Practice Address - Country:US
Practice Address - Phone:302-428-2987
Practice Address - Fax:302-428-2984
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00160100101YA0400X
NJ37CA00046700101YA0400X
DECD-0000078101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0077313Medicaid