Provider Demographics
NPI:1962502856
Name:GONZALES, MANUEL (MSW)
Entity Type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7211 WICKER AVE
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46323
Mailing Address - Country:US
Mailing Address - Phone:219-989-8064
Mailing Address - Fax:
Practice Address - Street 1:9330 S BROADWAY
Practice Address - Street 2:
Practice Address - City:CROOWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307
Practice Address - Country:US
Practice Address - Phone:219-662-5082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000399A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical