Provider Demographics
NPI:1770199507
Name:GONZALEZ, LAURA LISA (MA)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:LISA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 W FOSS AVE
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48505-2087
Mailing Address - Country:US
Mailing Address - Phone:810-835-9841
Mailing Address - Fax:810-407-9198
Practice Address - Street 1:7134 BLANKENSHIP CIR
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-2317
Practice Address - Country:US
Practice Address - Phone:810-742-7713
Practice Address - Fax:810-407-9198
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS25.293461320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities