Provider Demographics
NPI:1154966927
Name:GONZALES, LAUREN LYNNE (PHD)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:LYNNE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 S PORTLAND AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-1373
Mailing Address - Country:US
Mailing Address - Phone:702-768-1950
Mailing Address - Fax:
Practice Address - Street 1:1 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4213
Practice Address - Country:US
Practice Address - Phone:315-992-8318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-15
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023034103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical