Healthcare Provider Details

I. General information

NPI: 1972242576
Provider Name (Legal Business Name): MARY ROSE GONZALES LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY ROSE PERALTA LLMSW

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 1/2 S LAFAYETTE ST STE 202
GREENVILLE MI
48838-1967
US

IV. Provider business mailing address

PO BOX 10
MASON MI
48854-0010
US

V. Phone/Fax

Practice location:
  • Phone: 616-835-9292
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801122198
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801122198
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: