Provider Demographics
NPI:1659317832
Name:GONZALEZ, REBECA (PSYD)
Entity Type:Individual
Prefix:
First Name:REBECA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 OLD COUNTRY RD
Mailing Address - Street 2:SUITE 271
Mailing Address - City:CARLE PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11514-1801
Mailing Address - Country:US
Mailing Address - Phone:800-725-6280
Mailing Address - Fax:800-725-6380
Practice Address - Street 1:140 SAINT EDWARDS ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-3904
Practice Address - Country:US
Practice Address - Phone:718-858-6400
Practice Address - Fax:718-596-5067
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015788-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02532025Medicaid
NY01322XMedicare ID - Type UnspecifiedGHI MEDICARE #