Provider Demographics
NPI:1831456219
Name:GONZALEZ, CRISELDA
Entity type:Individual
Prefix:
First Name:CRISELDA
Middle Name:
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 1:1391 FOXLAND BLVD APT J303
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-4285
Mailing Address - Country:US
Mailing Address - Phone:615-569-1939
Mailing Address - Fax:
Practice Address - Street 1:2200 21ST AVE S STE 410
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37212-4929
Practice Address - Country:US
Practice Address - Phone:615-569-1939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3397960Medicaid
TX149984001Medicaid
TX676535Medicare PIN
TX207164901Medicaid