Provider Demographics
NPI:1619018074
Name:GONZALEZ, ALFRED (CCS, LCAS)
Entity Type:Individual
Prefix:MR
First Name:ALFRED
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:CCS, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 WILDOAT PL
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-2155
Mailing Address - Country:US
Mailing Address - Phone:919-250-0144
Mailing Address - Fax:
Practice Address - Street 1:1001 NAVAHO DR STE 150
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7368
Practice Address - Country:US
Practice Address - Phone:919-873-1551
Practice Address - Fax:919-873-1512
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNCSAPPB 494101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6110521Medicaid