Provider Demographics
NPI:1720180805
Name:GONZALEZ, HUGO
Entity Type:Individual
Prefix:
First Name:HUGO
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 N MAIN ST
Mailing Address - Street 2:SUITE # 4
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5757
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1070 MAIN ST
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4847
Practice Address - Country:US
Practice Address - Phone:401-727-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICSW00497104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIHG29643Medicaid
RIHG29643Medicaid