MEDICARE: MS. IVONNE D GONZALEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1437582855
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. IVONNE D GONZALEZ

Provider Business Mailing Address
First Line	:	14401 JOSE VEDRA BLVD
Second Line	:	#2801
City	:	JACKSONVILLE
State	:	FL
Zip	:	32250-2009
Country	:	US
Telephone Number	:	912-275-1157
Fax Number	:

Provider Business Practice Location Address
First Line	:	14401 JOSE VEDRA BLVD
Second Line	:	#2801
City	:	JACKSONVILLE
State	:	FL
Zip	:	32250-2009
Country	:	US
Telephone Number	:	912-275-1157
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2013
Last Update Date	:	08/21/2013

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