Provider Demographics
NPI:1760193080
Name:GONZALEZ, MARISOL (PSYCOLOGY)
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PSYCOLOGY
Other - Prefix:MRS
Other - First Name:MARISOL
Other - Middle Name:
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:URB JARDINES DE COUNTRY CLUB
Mailing Address - Street 2:CALLE 14 S 6
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00983-0000
Mailing Address - Country:US
Mailing Address - Phone:787-639-1012
Mailing Address - Fax:
Practice Address - Street 1:URB JARDINES DE COUNTRY CLUB
Practice Address - Street 2:CALLE 14 S 6
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00983-0000
Practice Address - Country:US
Practice Address - Phone:787-639-1012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-07
Last Update Date:2023-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7543103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR7543Other7543