Provider Demographics
NPI:1134370695
Name:GONZALEZ, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 LAWRENCE AVE
Mailing Address - Street 2:CHILDREN'S PROGRAM
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-1103
Mailing Address - Country:US
Mailing Address - Phone:718-436-7979
Mailing Address - Fax:718-436-0041
Practice Address - Street 1:160 LAWRENCE AVE
Practice Address - Street 2:CHILDREN'S PROGRAM
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-1103
Practice Address - Country:US
Practice Address - Phone:718-436-7979
Practice Address - Fax:718-436-0041
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool