Provider Demographics
NPI:1811698053
Name:GONZALEZ, WANDA
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:GONZALEZ
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 1:21 DAVIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-4643
Mailing Address - Country:US
Mailing Address - Phone:917-873-8653
Mailing Address - Fax:
Practice Address - Street 1:1124 ROUTE 94 STE 201
Practice Address - Street 2:
Practice Address - City:NEW WINDSOR
Practice Address - State:NY
Practice Address - Zip Code:12553-7258
Practice Address - Country:US
Practice Address - Phone:845-787-1359
Practice Address - Fax:845-787-1366
Is Sole Proprietor?:No
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115883-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker