Provider Demographics
NPI:1174196083
Name:GONZALEZ, MICHAEL AARON (CADC-R/CRM/PSS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:AARON
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:CADC-R/CRM/PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:620 NE 2ND ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7514
Practice Address - Country:US
Practice Address - Phone:971-274-3757
Practice Address - Fax:503-912-5740
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000105609175T00000X
OR21-CRM-479101YA0400X
ORT-22-1722101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500807475Medicaid