Provider Demographics
NPI:1003252255
Name:GONZALEZ, MARIA LOURDES (OTL)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:LOURDES
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:OTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:F18 CALLE DAMASCO
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00727-6744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:F18 CALLE DAMASCO
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00727-6744
Practice Address - Country:US
Practice Address - Phone:787-413-1242
Practice Address - Fax:787-744-0358
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1106174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist