Provider Demographics
NPI:1912677824
Name:GONZALEZ, CARLY ALICE
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ALICE
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 1:335 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4036
Mailing Address - Country:US
Mailing Address - Phone:860-643-3210
Mailing Address - Fax:
Practice Address - Street 1:140 COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-3098
Practice Address - Country:US
Practice Address - Phone:860-482-8796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)