Provider Demographics
NPI:1326426701
Name:GONZALEZ, MONA LISA (DC, QP)
Entity Type:Individual
Prefix:MS
First Name:MONA
Middle Name:LISA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:DC, QP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:542 SNELLING AVE S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1565
Mailing Address - Country:US
Mailing Address - Phone:651-403-6034
Mailing Address - Fax:651-340-7958
Practice Address - Street 1:542 SNELLING AVE S
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-1565
Practice Address - Country:US
Practice Address - Phone:651-403-6034
Practice Address - Fax:651-340-7958
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator