Provider Demographics
NPI:1841535267
Name:GAITAN-GONZALEZ, MILDRED AZUCENA (LCSW)
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:AZUCENA
Last Name:GAITAN-GONZALEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 MAIN AVE N
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6101
Mailing Address - Country:US
Mailing Address - Phone:208-733-3024
Mailing Address - Fax:208-733-0929
Practice Address - Street 1:160 MAIN AVE N
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6101
Practice Address - Country:US
Practice Address - Phone:208-733-3024
Practice Address - Fax:208-733-0929
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-11
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-32352104100000X
IDLCSW-342171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker