Provider Demographics
NPI:1902673015
Name:GONZALES, KRISTINE M (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:M
Last Name:GONZALES
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:ROSSFORD
Mailing Address - State:OH
Mailing Address - Zip Code:43460-1248
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1627 HENTHORNE DR STE C
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1370
Practice Address - Country:US
Practice Address - Phone:419-740-5449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-08
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1000266104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker