Basic Information
| Provider Information | |||||||||
| NPI: | 1548403272 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALES | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | LOURDES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 155 CRYSTAL RUN RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109414028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457036999 | ||||||||
| FaxNumber: | 8457036297 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 CENTEROCK RD | ||||||||
| Address2: | |||||||||
| City: | WEST NYACK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109942215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457036999 | ||||||||
| FaxNumber: | 8457036297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2009 | ||||||||
| LastUpdateDate: | 09/09/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 015211-1 | NY | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | 015211-1 | NY | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TA0700X | 015211-1 | NY | N | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging | 103TH0004X | 015211-1 | NY | N | Behavioral Health & Social Service Providers | Psychologist | Health | 103TH0100X | 015211-1 | NY | N | Behavioral Health & Social Service Providers | Psychologist | Health Service | 103TR0400X | 015211-1 | NY | N | Behavioral Health & Social Service Providers | Psychologist | Rehabilitation | 103TF0000X | 015211-1 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Family |
No ID Information.