Healthcare Provider Details

I. General information

NPI: 1730744319
Provider Name (Legal Business Name): HANNAH MARIE GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 RENAISSANCE CENTER SUITE 2600
GRAND RAPIDS MI
49506
US

IV. Provider business mailing address

10897 48TH AVE UNIT V2
ALLENDALE MI
49401-8151
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax:
Mailing address:
  • Phone: 810-986-5076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number247200000X
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: