Healthcare Provider Details

I. General information

NPI: 1437524642
Provider Name (Legal Business Name): MICHAEL GONZALES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2015
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3995 MARCOLA RD
SPRINGFIELD OR
97477-7948
US

IV. Provider business mailing address

3995 MARCOLA RD
SPRINGFIELD OR
97477-7948
US

V. Phone/Fax

Practice location:
  • Phone: 541-726-1465
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: