Provider Demographics
NPI:1760175855
Name:GONZALES, MICHELE MARIE
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:MARIE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2406 N HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:TN
Mailing Address - Zip Code:37172-3912
Mailing Address - Country:US
Mailing Address - Phone:615-812-5010
Mailing Address - Fax:
Practice Address - Street 1:247 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-7320
Practice Address - Country:US
Practice Address - Phone:615-314-3292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
TN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician