Provider Demographics
NPI:1679755672
Name:GONZALEZ, HERMAN (AAS)
Entity type:Individual
Prefix:
First Name:HERMAN
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:AAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:SWAN LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12783-0012
Mailing Address - Country:US
Mailing Address - Phone:845-292-8770
Mailing Address - Fax:845-292-4206
Practice Address - Street 1:20 COMMUNITY LN
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-2851
Practice Address - Country:US
Practice Address - Phone:845-292-8770
Practice Address - Fax:845-292-4206
Is Sole Proprietor?:No
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)