Provider Demographics
NPI:1922259191
Name:GONZALEZ, MICAEL
Entity Type:Individual
Prefix:
First Name:MICAEL
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:387 17TH ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3354
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:387 17TH ST
Practice Address - Street 2:SUITE 210
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-3354
Practice Address - Country:US
Practice Address - Phone:650-248-7313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26486103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical