Provider Demographics
NPI:1528192671
Name:GONZALEZ, ROSA
Entity Type:Individual
Prefix:
First Name:ROSA
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 1:654 PONTIAC AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-4730
Mailing Address - Country:US
Mailing Address - Phone:401-453-4451
Mailing Address - Fax:401-228-6654
Practice Address - Street 1:654 PONTIAC AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-4730
Practice Address - Country:US
Practice Address - Phone:401-453-4451
Practice Address - Fax:401-228-6654
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIELI-0047171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator