Provider Demographics
NPI:1376221267
Name:BASTOW-GONZALEZ, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BASTOW-GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 IRVING AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302-2123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 IRVING AVE
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-2123
Practice Address - Country:US
Practice Address - Phone:856-507-2730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC061971001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical