Provider Demographics
NPI:1376992180
Name:MATOS GONZALEZ, LOURDES VANESSA (CSW)
Entity Type:Individual
Prefix:MS
First Name:LOURDES
Middle Name:VANESSA
Last Name:MATOS GONZALEZ
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. VALLE ALTO
Mailing Address - Street 2:1531 ALTURA
Mailing Address - City:PONCE
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00730
Mailing Address - Country:UM
Mailing Address - Phone:787-202-4789
Mailing Address - Fax:
Practice Address - Street 1:URB. VALLE ALTO
Practice Address - Street 2:1531 ALTURA
Practice Address - City:PONCE
Practice Address - State:PUERTO RICO
Practice Address - Zip Code:00730
Practice Address - Country:UM
Practice Address - Phone:787-202-4789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-13
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR134201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical