Provider Demographics
NPI:1588019574
Name:GONZALEZ, MICHAELEEN (LMT)
Entity Type:Individual
Prefix:
First Name:MICHAELEEN
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 WASHBURN WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-4304
Mailing Address - Country:US
Mailing Address - Phone:541-887-2507
Mailing Address - Fax:541-887-2508
Practice Address - Street 1:1775 WASHBURN WAY
Practice Address - Street 2:SUITE A
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-4304
Practice Address - Country:US
Practice Address - Phone:541-887-2507
Practice Address - Fax:541-887-2508
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21988305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service