Provider Demographics
NPI:1528309580
Name:GONZALEZ, ELISSA
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELISSA
Other - Middle Name:
Other - Last Name:BRADFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:221 SCHOOL HOUSE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-1805
Mailing Address - Country:US
Mailing Address - Phone:912-409-7561
Mailing Address - Fax:912-673-0178
Practice Address - Street 1:221 SCHOOL HOUSE CREEK DR
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-1805
Practice Address - Country:US
Practice Address - Phone:912-409-7561
Practice Address - Fax:912-673-0178
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-14
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management