Provider Demographics
NPI:1487024642
Name:GONZALEZ, DESERAE
Entity Type:Individual
Prefix:
First Name:DESERAE
Middle Name:
Last Name: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 1:3851 ROGER BROOKE DR
Mailing Address - Street 2:BAMC MCHE-QD (CREDS)
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3851 ROGER BROOKE DR
Practice Address - Street 2:BAMC MCHE-QD (CREDS)
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4501
Practice Address - Country:US
Practice Address - Phone:770-357-2400
Practice Address - Fax:678-547-3163
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX57097104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker