Provider Demographics
NPI:1659804797
Name:GONZALEZ, LUZ AMALYA (CSAC, RESIDENT IN CO)
Entity Type:Individual
Prefix:
First Name:LUZ
Middle Name:AMALYA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:CSAC, RESIDENT IN CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 42178
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22404-2178
Mailing Address - Country:US
Mailing Address - Phone:540-479-2064
Mailing Address - Fax:
Practice Address - Street 1:120 FALCON DR
Practice Address - Street 2:SUITE 6
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-1900
Practice Address - Country:US
Practice Address - Phone:540-479-2064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710102137101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VADON'T HAVEMedicaid
VADON'T HAVE NEWOtherMAGELLAN NETWORK PROVIDER