Provider Demographics
NPI:1366801227
Name:GONZALEZ, SUSANA (LPC; ACD)
Entity type:Individual
Prefix:MS
First Name:SUSANA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LPC; ACD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S ROLLIE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1508
Mailing Address - Country:US
Mailing Address - Phone:303-286-4560
Mailing Address - Fax:303-286-4589
Practice Address - Street 1:1115 2ND ST
Practice Address - Street 2:
Practice Address - City:FORT LUPTON
Practice Address - State:CO
Practice Address - Zip Code:80621-1745
Practice Address - Country:US
Practice Address - Phone:303-697-2583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-19
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000355101YA0400X
CO0005052101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)