Provider Demographics
NPI:1689667024
Name:GONZALES, DEBORAH MARIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:MARIE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LCSW
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 772244
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-2244
Mailing Address - Country:US
Mailing Address - Phone:907-694-7031
Mailing Address - Fax:907-745-1185
Practice Address - Street 1:11517 OLD GLENN HWY
Practice Address - Street 2:SUITE # 203
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7312
Practice Address - Country:US
Practice Address - Phone:907-694-7031
Practice Address - Fax:907-745-1185
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0006711041C0700X
AK8411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2878883AMedicare ID - Type Unspecified