MEDICARE: MICHELLE GONZALEZ

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	103TS0200X	School Psychologist		NY

General Provider Information

NPI Number	:	1376117200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE GONZALEZ

Provider Business Mailing Address
First Line	:	11919 18TH AVE
Second Line	:
City	:	COLLEGE POINT
State	:	NY
Zip	:	11356-2106
Country	:	US
Telephone Number	:	347-956-6041
Fax Number	:

Provider Business Practice Location Address
First Line	:	11919 18TH AVE
Second Line	:
City	:	COLLEGE POINT
State	:	NY
Zip	:	11356-2106
Country	:	US
Telephone Number	:	347-956-6041
Fax Number	:

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

Provider Enumeration Date	:	05/15/2021
Last Update Date	:	05/15/2021

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Directions to “ MICHELLE GONZALEZ ” Practice Location

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