Provider Demographics
NPI:1952648776
Name:GONZALEZ, JOHNNY MANUEL
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:MANUEL
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 1:328 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-3794
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:328 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-3794
Practice Address - Country:US
Practice Address - Phone:508-765-9101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor