Basic Information
| Provider Information | |||||||||
| NPI: | 1801436209 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | LACI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1302 NE SOUTH ST | ||||||||
| Address2: | |||||||||
| City: | JENSEN BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349574847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604556861 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1601 NE BRAILLE PL | ||||||||
| Address2: | |||||||||
| City: | JENSEN BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349575345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723200770 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2020 | ||||||||
| LastUpdateDate: | 01/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.