Provider Demographics
NPI:1881412682
Name:GONZALEZ, LUIS JESUS
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:JESUS
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 1:4719 COLONEL ASHTON PL
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-2873
Mailing Address - Country:US
Mailing Address - Phone:202-967-5739
Mailing Address - Fax:
Practice Address - Street 1:903 BRIGHTSEAT RD
Practice Address - Street 2:
Practice Address - City:LANDOVER
Practice Address - State:MD
Practice Address - Zip Code:20785-4725
Practice Address - Country:US
Practice Address - Phone:202-967-5739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor