Provider Demographics
NPI:1619060340
Name:GONZALES, RAUL MUNGIA (MSW)
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:MUNGIA
Last Name:GONZALES
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 ARAGON
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48906
Mailing Address - Country:US
Mailing Address - Phone:517-321-8356
Mailing Address - Fax:
Practice Address - Street 1:4970 NORTHWIND
Practice Address - Street 2:STE220
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5032
Practice Address - Country:US
Practice Address - Phone:989-345-1000
Practice Address - Fax:989-345-5803
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801012156104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIS01882Medicare UPIN