Provider Demographics
NPI:1386052892
Name:GONZALES, SUSAN (MSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 N CENTRAL AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2902
Mailing Address - Country:US
Mailing Address - Phone:602-685-6120
Mailing Address - Fax:602-265-6973
Practice Address - Street 1:1802 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-8134
Practice Address - Country:US
Practice Address - Phone:602-302-1812
Practice Address - Fax:602-258-6140
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW13451104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker