Provider Demographics
NPI:1477696326
Name:GONZALEZ, MYRNA DORIS (MACCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:MYRNA
Middle Name:DORIS
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 CLARKE ST APT 1B
Mailing Address - Street 2:
Mailing Address - City:CATSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12414-1467
Mailing Address - Country:US
Mailing Address - Phone:631-513-5461
Mailing Address - Fax:
Practice Address - Street 1:37 CLARKE ST APT 1B
Practice Address - Street 2:
Practice Address - City:CATSKILL
Practice Address - State:NY
Practice Address - Zip Code:12414-1467
Practice Address - Country:US
Practice Address - Phone:631-513-5461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005143-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist