Provider Demographics
NPI:1720550460
Name:GONZALEZ, MICHELLE MARIE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
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 1:954 COUNTY ROAD 140
Mailing Address - Street 2:
Mailing Address - City:FLORESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78114-4185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19965 FM 3175
Practice Address - Street 2:
Practice Address - City:LYTLE
Practice Address - State:TX
Practice Address - Zip Code:78052-3481
Practice Address - Country:US
Practice Address - Phone:210-357-0318
Practice Address - Fax:830-709-5493
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115448235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist