Provider Demographics
NPI:1275394223
Name:GONZALEZ, SALLY ANNE (LPC)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:ANNE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51363 TIMES SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-2456
Mailing Address - Country:US
Mailing Address - Phone:815-975-8572
Mailing Address - Fax:
Practice Address - Street 1:47818 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48317-3373
Practice Address - Country:US
Practice Address - Phone:586-323-3260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401222955101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional