Provider Demographics
NPI:1760959464
Name:GONZALEZ, AMANTE JORDAN (LLPC)
Entity Type:Individual
Prefix:
First Name:AMANTE
Middle Name:JORDAN
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 INTERNATIONAL CT APT A47
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-1720
Mailing Address - Country:US
Mailing Address - Phone:269-944-9230
Mailing Address - Fax:
Practice Address - Street 1:5675 FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49127-1033
Practice Address - Country:US
Practice Address - Phone:269-429-7727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016896101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional