Provider Demographics
NPI:1447406517
Name:GONZALEZ, MICHELLE AMEZAGA (PSYD, LMHC)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:AMEZAGA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PSYD, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5915 PONCE DE LEON BLVD STE 12
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-2435
Mailing Address - Country:US
Mailing Address - Phone:305-972-0818
Mailing Address - Fax:
Practice Address - Street 1:5915 PONCE DE LEON BLVD STE 12
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2435
Practice Address - Country:US
Practice Address - Phone:305-972-0818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-08
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9301101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11962818OtherCAQH