Provider Demographics
NPI:1902116114
Name:GONZALEZ, CARMEN ISABEL (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:ISABEL
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PENNSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08070-1417
Mailing Address - Country:US
Mailing Address - Phone:856-678-9400
Mailing Address - Fax:
Practice Address - Street 1:193 N BROADWAY
Practice Address - Street 2:
Practice Address - City:PENNSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08070-1417
Practice Address - Country:US
Practice Address - Phone:856-678-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1084351103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst