Provider Demographics
NPI:1578370920
Name:GONZALES, MARCOS (LSW)
Entity type:Individual
Prefix:
First Name:MARCOS
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 W TAYLOR ST UNIT 1078
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4623
Mailing Address - Country:US
Mailing Address - Phone:818-900-3965
Mailing Address - Fax:
Practice Address - Street 1:2249 W IOWA ST APT 2F
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-5221
Practice Address - Country:US
Practice Address - Phone:818-900-3965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-18
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.1139221041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical