Provider Demographics
NPI:1194333120
Name:GONZALEZ, PAULETTE ALEKXA
Entity type:Individual
Prefix:
First Name:PAULETTE
Middle Name:ALEKXA
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 1:1385 PENATAQUIT AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-5126
Mailing Address - Country:US
Mailing Address - Phone:631-428-4058
Mailing Address - Fax:
Practice Address - Street 1:2 ROOSEVELT AVE STE 300
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-3064
Practice Address - Country:US
Practice Address - Phone:516-758-4119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2021-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NY111122104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator