Provider Demographics
NPI:1710253182
Name:GONZALEZ, ADRIANA LAURA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ADRIANA
Middle Name:LAURA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 HILLCREST TER
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-6128
Mailing Address - Country:US
Mailing Address - Phone:845-535-9119
Mailing Address - Fax:845-818-3500
Practice Address - Street 1:85 HILLCREST TER
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450
Practice Address - Country:US
Practice Address - Phone:845-535-9119
Practice Address - Fax:845-818-3500
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003162103T00000X, 103TC0700X
NY019350103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03535733Medicaid
CT04675774Medicaid