Provider Demographics
NPI:1972242576
Name:GONZALES, MARY ROSE (LLMSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ROSE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:ROSE
Other - Last Name:PERALTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLMSW
Mailing Address - Street 1:309 1/2 S LAFAYETTE ST STE 202
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-1967
Mailing Address - Country:US
Mailing Address - Phone:616-835-9292
Mailing Address - Fax:
Practice Address - Street 1:309 1/2 S LAFAYETTE ST STE 202
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-1967
Practice Address - Country:US
Practice Address - Phone:616-835-9292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2022-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical