Provider Demographics
NPI:1215738265
Name:GONZAGA, KIM MARIE (LCDP)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:GONZAGA
Suffix:
Gender:
Credentials:LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 PILGRIM DR
Mailing Address - Street 2:
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-2113
Mailing Address - Country:US
Mailing Address - Phone:617-803-8622
Mailing Address - Fax:
Practice Address - Street 1:3045 TOWER HILL RD
Practice Address - Street 2:
Practice Address - City:SAUNDERSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02874-1501
Practice Address - Country:US
Practice Address - Phone:401-789-0934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-24
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICDP01032101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)