Provider Demographics
NPI:1376223321
Name:MARCOS-GONZALEZ, EVEN MARK (LMSW, CASAC-T)
Entity Type:Individual
Prefix:
First Name:EVEN
Middle Name:MARK
Last Name:MARCOS-GONZALEZ
Suffix:
Gender:M
Credentials:LMSW, CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 PARK LN
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-1105
Mailing Address - Country:US
Mailing Address - Phone:631-478-3195
Mailing Address - Fax:
Practice Address - Street 1:151 BURRS LN
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-6052
Practice Address - Country:US
Practice Address - Phone:516-671-1253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY118664-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker