Provider Demographics
NPI:1134510415
Name:GONZALES, KATHERINE (LMSW, QIDP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LMSW, QIDP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:KOOIMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW, QIDP
Mailing Address - Street 1:3353 LOUSMA DR SE
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49548-2251
Mailing Address - Country:US
Mailing Address - Phone:616-241-6258
Mailing Address - Fax:616-241-6470
Practice Address - Street 1:3353 LOUSMA DR SE
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49548-2251
Practice Address - Country:US
Practice Address - Phone:616-241-6258
Practice Address - Fax:616-241-6470
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801096861171M00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator