Provider Demographics
NPI:1578686556
Name:GONZALEZ, MARILYN N (CC)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:N
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4160 TUDOR CENTRE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5904
Mailing Address - Country:US
Mailing Address - Phone:907-729-3171
Mailing Address - Fax:907-729-6366
Practice Address - Street 1:4160 TUDOR CENTRE DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5901
Practice Address - Country:US
Practice Address - Phone:907-729-3171
Practice Address - Fax:907-729-6366
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM9200Medicaid