Provider Demographics
NPI:1679270920
Name:GONZALEZ, YVELISSE (CRC)
Entity type:Individual
Prefix:MRS
First Name:YVELISSE
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:
Credentials:CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:EXETER
Mailing Address - State:PA
Mailing Address - Zip Code:18643-1434
Mailing Address - Country:US
Mailing Address - Phone:570-342-8434
Mailing Address - Fax:570-299-2521
Practice Address - Street 1:121 MOOSIC RD
Practice Address - Street 2:
Practice Address - City:OLD FORGE
Practice Address - State:PA
Practice Address - Zip Code:18518-2082
Practice Address - Country:US
Practice Address - Phone:570-342-8434
Practice Address - Fax:570-299-2521
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252Y00000X
PAAPC000966101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No252Y00000XAgenciesEarly Intervention Provider Agency