Provider Demographics
NPI:1134981194
Name:GONZALES, MIKAELA
Entity type:Individual
Prefix:
First Name:MIKAELA
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 HIGHWAY 365 STE J
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77642-7719
Mailing Address - Country:US
Mailing Address - Phone:409-344-9089
Mailing Address - Fax:409-344-9390
Practice Address - Street 1:4700 HIGHWAY 365 STE J
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-7719
Practice Address - Country:US
Practice Address - Phone:409-344-9089
Practice Address - Fax:409-344-9390
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX119651235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist