Provider Demographics
NPI:1821263120
Name:MATTHEW B. GONZALEZ, PSY.D., P.C.
Entity Type:Organization
Organization Name:MATTHEW B. GONZALEZ, PSY.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:B
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:313-410-9626
Mailing Address - Street 1:1660 PICCARD DR
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-6693
Mailing Address - Country:US
Mailing Address - Phone:313-410-9626
Mailing Address - Fax:
Practice Address - Street 1:1660 PICCARD DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-6693
Practice Address - Country:US
Practice Address - Phone:313-410-9626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMG224080103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680H224080OtherBLUE CROSS
MI0P14420Medicare PIN