Provider Demographics
NPI:1134366792
Name:GONZALEZ, MIGUEL A (PHD)
Entity type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:A
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 VALLEYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-3280
Mailing Address - Country:US
Mailing Address - Phone:386-259-0647
Mailing Address - Fax:
Practice Address - Street 1:1310 MAXIMILLIAN ST
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-6502
Practice Address - Country:US
Practice Address - Phone:386-259-0647
Practice Address - Fax:386-860-0074
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-19
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT2595106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist