Provider Demographics
NPI:1457447963
Name:GONZALEZ, IRAIDA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:IRAIDA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 CHALKSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-4728
Mailing Address - Country:US
Mailing Address - Phone:401-456-4807
Mailing Address - Fax:
Practice Address - Street 1:825 CHALKSTONE AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4728
Practice Address - Country:US
Practice Address - Phone:401-456-4807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3030637174400000X
RICSW016691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No174400000XOther Service ProvidersSpecialist