MEDICARE: MIKAELA GONZALES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	119651	TX

General Provider Information

NPI Number	:	1134981194
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKAELA GONZALES

Provider Business Mailing Address
First Line	:	4700 HIGHWAY 365 STE J
Second Line	:
City	:	PORT ARTHUR
State	:	TX
Zip	:	77642-7719
Country	:	US
Telephone Number	:	409-344-9089
Fax Number	:	409-344-9390

Provider Business Practice Location Address
First Line	:	4700 HIGHWAY 365 STE J
Second Line	:
City	:	PORT ARTHUR
State	:	TX
Zip	:	77642-7719
Country	:	US
Telephone Number	:	409-344-9089
Fax Number	:	409-344-9390

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2024
Last Update Date	:	01/25/2024

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Directions to “ MIKAELA GONZALES ” Practice Location

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