Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003109307 |
---|---|
Provider Name | Michelle Gonzalez |
First Address | Dixon, IL 61021-2850 |
Second Address | Dixon, IL 61021-2850 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/05/2011 |
Last Update Date | 25/05/2011 |