Healthcare Provider Details

I. General information

NPI: 1881410470
Provider Name (Legal Business Name): MIGUEL GONZALEZ M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2024
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8115 164TH ST
JAMAICA NY
11432-1118
US

IV. Provider business mailing address

8913 138TH ST
JAMAICA NY
11435-4154
US

V. Phone/Fax

Practice location:
  • Phone: 718-380-3000
  • Fax:
Mailing address:
  • Phone: 347-858-2336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: