Provider Demographics
NPI:1346654399
Name:GONZALEZ, EDWARD (LCSW & LDAC)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:LCSW & LDAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1329 BURNSIDE AVE APT B3
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-1575
Mailing Address - Country:US
Mailing Address - Phone:516-652-2100
Mailing Address - Fax:
Practice Address - Street 1:627 MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-5181
Practice Address - Country:US
Practice Address - Phone:860-324-0042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1090101YA0400X
CT0102791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)