Provider Demographics
NPI:1255678041
Name:GONZALEZ, SAMANTHA J (LMSW)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:J
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4465 W MILHAM AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-1708
Mailing Address - Country:US
Mailing Address - Phone:231-742-0792
Mailing Address - Fax:
Practice Address - Street 1:190 E MICHIGAN AVE STE A100
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49014-4019
Practice Address - Country:US
Practice Address - Phone:269-565-3936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-14
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010936451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical