Basic Information
| Provider Information | |||||||||
| NPI: | 1215488358 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONCALVES | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | LELIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2195 ARDENNE DR | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481051477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346585642 | ||||||||
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| Practice Location | |||||||||
| Address1: | 555 TOWNER ST | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481985752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345443000 | ||||||||
| FaxNumber: | 7345446732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2016 | ||||||||
| LastUpdateDate: | 10/24/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801094395 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.