Basic Information
| Provider Information | |||||||||
| NPI: | 1033519335 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALES | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TRINGALI | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | ROSE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 17414 BRADY | ||||||||
| Address2: | |||||||||
| City: | REDFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482402100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139293437 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20600 EUREKA RD STE 800 | ||||||||
| Address2: | |||||||||
| City: | TAYLOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481805343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347857700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2014 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801106684 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.