Provider Demographics
NPI:1851171706
Name:GONZALEZ, JELISA (LMSW)
Entity Type:Individual
Prefix:MISS
First Name:JELISA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 RIMMON HILL RD
Mailing Address - Street 2:
Mailing Address - City:BEACON FALLS
Mailing Address - State:CT
Mailing Address - Zip Code:06403-1028
Mailing Address - Country:US
Mailing Address - Phone:203-554-4212
Mailing Address - Fax:
Practice Address - Street 1:225 N MAIN ST STE 80
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-4926
Practice Address - Country:US
Practice Address - Phone:860-506-7905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8202104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker