Provider Demographics
NPI:1447013289
Name:GONZALEZ, MIGUEL ANGEL
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ANGEL
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 NW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-5987
Mailing Address - Country:US
Mailing Address - Phone:706-461-9566
Mailing Address - Fax:
Practice Address - Street 1:1201 S PROCTOR ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2047
Practice Address - Country:US
Practice Address - Phone:706-461-9566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician