Provider Demographics
NPI:1568521334
Name:GONZALES, KRISTIN MICHELLE (LPC)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MICHELLE
Last Name:GONZALES
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 1:3311 PACKERLAND DR STE A
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-9539
Mailing Address - Country:US
Mailing Address - Phone:920-338-0100
Mailing Address - Fax:920-338-0103
Practice Address - Street 1:3311 PACKERLAND DR STE A
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-9539
Practice Address - Country:US
Practice Address - Phone:920-338-0100
Practice Address - Fax:920-338-0103
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2760-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1568521334OtherINSURERS
WI205885103OtherTIN