Provider Demographics
NPI:1871083626
Name:GONZALEZ, KRISTIN GRACE (LSW)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:GRACE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 MIAMISBURG CENTERVILLE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:WEST CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-4052
Mailing Address - Country:US
Mailing Address - Phone:937-866-4021
Mailing Address - Fax:
Practice Address - Street 1:1129 MIAMISBURG CENTERVILLE RD STE 201
Practice Address - Street 2:
Practice Address - City:WEST CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:45449-4052
Practice Address - Country:US
Practice Address - Phone:937-866-4021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0031772104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker