Provider Demographics
NPI:1720747090
Name:GONZALEZ, MARIELENA
Entity type:Individual
Prefix:
First Name:MARIELENA
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 1:405 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-3006
Mailing Address - Country:US
Mailing Address - Phone:847-441-5600
Mailing Address - Fax:
Practice Address - Street 1:7205 JARNECKE AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46324-2435
Practice Address - Country:US
Practice Address - Phone:219-670-2768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator