Provider Demographics
NPI:1164904124
Name:GONZALEZ, MIGUEL (MS,OBLPCT LPC INTERN)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MS,OBLPCT LPC INTERN
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 946
Mailing Address - Street 2:
Mailing Address - City:PHILOMATH
Mailing Address - State:OR
Mailing Address - Zip Code:97370-0946
Mailing Address - Country:US
Mailing Address - Phone:503-562-9505
Mailing Address - Fax:
Practice Address - Street 1:4890 32ND AVE SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97317-9350
Practice Address - Country:US
Practice Address - Phone:503-588-5647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health