Provider Demographics
NPI:1780665232
Name:GONZALEZ, LAURA ALICIA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ALICIA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:LAURA
Other - Middle Name:GONZALEZ
Other - Last Name:BORGOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:4837 AVE ISLA VERDE
Mailing Address - Street 2:COND GIRASOL APT # 508
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00979-5418
Mailing Address - Country:US
Mailing Address - Phone:787-594-5686
Mailing Address - Fax:787-982-2554
Practice Address - Street 1:107 ORTEGON AVE, SUITE 206
Practice Address - Street 2:CAPARRA GALLERY BLDG
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00909
Practice Address - Country:US
Practice Address - Phone:787-594-5686
Practice Address - Fax:787-982-2554
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR70103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR8945Medicare UPIN
PR2201Medicare UPIN
PR1703Medicare UPIN
PR84511Medicare ID - Type UnspecifiedPROVIDER #
PR219022Medicare UPIN
PR2512Medicare UPIN