Provider Demographics
NPI:1497701361
Name:GONZALEZ, MATTHEW B (PSYD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:B
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 PICCARD DR
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-6693
Mailing Address - Country:US
Mailing Address - Phone:313-410-9626
Mailing Address - Fax:
Practice Address - Street 1:1660 PICCARD DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-6693
Practice Address - Country:US
Practice Address - Phone:313-410-9626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007510103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680H224080OtherBCBSM
MI680H224080OtherBCBSM
MIOP14420Medicare PIN