Provider Demographics
NPI:1760097018
Name:GONZALO, JOSLAINEZ
Entity Type:Individual
Prefix:
First Name:JOSLAINEZ
Middle Name:
Last Name:GONZALO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 MILLER STREET
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NH
Mailing Address - Zip Code:07114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:47 MILLER STREET,
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07114
Practice Address - Country:US
Practice Address - Phone:973-639-1950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0218341Medicaid