Provider Demographics
NPI:1699836304
Name:GONZALEZ, ETHEL (LCSW R)
Entity Type:Individual
Prefix:MRS
First Name:ETHEL
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LCSW R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3424 77TH ST
Mailing Address - Street 2:APT#35
Mailing Address - City:JACKSON HTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372
Mailing Address - Country:US
Mailing Address - Phone:718-898-9615
Mailing Address - Fax:
Practice Address - Street 1:3424 77TH ST
Practice Address - Street 2:APT#35
Practice Address - City:JACKSON HTS
Practice Address - State:NY
Practice Address - Zip Code:11372
Practice Address - Country:US
Practice Address - Phone:718-898-9615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO256971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical