Provider Demographics
NPI:1871793521
Name:GONZALEZ, ELISE A
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:A
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HIGH SERVICE AVE
Mailing Address - Street 2:4TH FL. MARION HALL, ATT: R SOARES
Mailing Address - City:N PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5113
Mailing Address - Country:US
Mailing Address - Phone:401-456-3309
Mailing Address - Fax:401-456-3762
Practice Address - Street 1:21 PEACE ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-1510
Practice Address - Country:US
Practice Address - Phone:401-456-3309
Practice Address - Fax:401-456-3762
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI00785104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI00785OtherCSW LICENCE
RI007059635Medicare PIN