Provider Demographics
NPI:1912697277
Name:GONZAGA MOROCHO, LESLIE (LMSW)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:GONZAGA MOROCHO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 DOANE AVE
Mailing Address - Street 2:
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713-1529
Mailing Address - Country:US
Mailing Address - Phone:631-922-3483
Mailing Address - Fax:
Practice Address - Street 1:606 JOHNSON AVE STE 30
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-2688
Practice Address - Country:US
Practice Address - Phone:631-617-4796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113850104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker