Provider Demographics
NPI:1215419254
Name:GONZALEZ, MICHELLE LEE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEE
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 1:106 SENECA ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-2334
Mailing Address - Country:US
Mailing Address - Phone:347-596-0251
Mailing Address - Fax:
Practice Address - Street 1:106 SENECA ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-2334
Practice Address - Country:US
Practice Address - Phone:347-596-0251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency