Provider Demographics
NPI:1659498913
Name:GONZALEZ, MIGUEL ANGEL (EDS)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ANGEL
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1453 N. MAIN ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:SAN LUIS
Mailing Address - State:AZ
Mailing Address - Zip Code:85349
Mailing Address - Country:US
Mailing Address - Phone:928-627-6567
Mailing Address - Fax:
Practice Address - Street 1:1453 N. MAIN ST.
Practice Address - Street 2:SUITE F
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349
Practice Address - Country:US
Practice Address - Phone:928-627-6567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ838188OtherAHCCCS