=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386828622
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARTHA GONZALEZ-MICHAELIS LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2007
-----------------------------------------------------
Last Update Date | 05/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 609 CHEEK SPARGER RD SUITE 200
-----------------------------------------------------
City | COLLEYVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76034-3881
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-557-4578
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3605 BORDEAUX LN
-----------------------------------------------------
City | HURST
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76054-2092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-557-4578
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 59651
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------