Provider Demographics
NPI:1477706026
Name:GONZALEZ, MIRIAM (LCSW)
Entity Type:Individual
Prefix:
First Name:MIRIAM
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 1:2071 N RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-2733
Mailing Address - Country:US
Mailing Address - Phone:718-668-1655
Mailing Address - Fax:
Practice Address - Street 1:25 CHAPEL ST
Practice Address - Street 2:SUITE 704
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-1952
Practice Address - Country:US
Practice Address - Phone:718-522-7300
Practice Address - Fax:718-522-5280
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR029450-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical