Provider Demographics
NPI:1730730383
Name:GONZALEZ, VANESSA
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:138 SMOKEY WAY
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-2843
Mailing Address - Country:US
Mailing Address - Phone:786-510-2672
Mailing Address - Fax:
Practice Address - Street 1:500 S MAIN ST STE 113
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-3550
Practice Address - Country:US
Practice Address - Phone:407-777-4373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-25
Last Update Date:2025-07-25
Deactivation Date:2020-07-20
Deactivation Code:
Reactivation Date:2020-07-28
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
FLSW204421041C0700X
NCC0183321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor