Provider Demographics
NPI:1558814129
Name:GONZALEZ, IMARI ROCHELL
Entity Type:Individual
Prefix:
First Name:IMARI
Middle Name:ROCHELL
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 1:1400 CENTRE ST STE 207
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-2415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 CENTRE ST STE 207
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02459-2415
Practice Address - Country:US
Practice Address - Phone:617-332-2282
Practice Address - Fax:508-302-0507
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-29
Last Update Date:2023-06-15
Deactivation Date:2022-01-06
Deactivation Code:
Reactivation Date:2022-02-03
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor