Provider Demographics
NPI:1891511242
Name:VIDES GONZALEZ, GINA BERNICE
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:BERNICE
Last Name:VIDES 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 1:200 E VINE ST STE A
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-5531
Mailing Address - Country:US
Mailing Address - Phone:410-543-7119
Mailing Address - Fax:
Practice Address - Street 1:200 E VINE ST STE A
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-5531
Practice Address - Country:US
Practice Address - Phone:410-543-7119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD280461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical