Provider Demographics
NPI:1750311981
Name:ANGULO DE GONZALEZ, MARITZA (LCSW)
Entity Type:Individual
Prefix:
First Name:MARITZA
Middle Name:
Last Name:ANGULO DE GONZALEZ
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 1:48 STORRS ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-4258
Mailing Address - Country:US
Mailing Address - Phone:860-965-0635
Mailing Address - Fax:
Practice Address - Street 1:48 STORRS ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-4258
Practice Address - Country:US
Practice Address - Phone:860-965-0635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0045971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT321636OtherMHN
CT7819545OtherAETNA
CT004234952Medicaid
CT494566OtherVALUE OPTIONS
CT140004597CT01OtherANTHEM BCBS
CT398612OtherMAGELLAN BEHAVIORAL HEALT
CT800003244Medicare ID - Type UnspecifiedMEDICARE