Provider Demographics
NPI:1790374809
Name:GONZALEZ AGOSTO, MARITZA
Entity Type:Individual
Prefix:
First Name:MARITZA
Middle Name:
Last Name:GONZALEZ AGOSTO
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 1:3RD AVENUE CHESAPEAKE PLAZA #9
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:OH
Mailing Address - Zip Code:45619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:757 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-1607
Practice Address - Country:US
Practice Address - Phone:513-968-8939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
OHS.23093261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0004999Medicaid