Provider Demographics
NPI:1003428228
Name:GONZALEZ, PEDRO MARIO (MS, CTRS)
Entity Type:Individual
Prefix:MR
First Name:PEDRO
Middle Name:MARIO
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MS, CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 SWAN HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-5108
Mailing Address - Country:US
Mailing Address - Phone:516-528-3222
Mailing Address - Fax:
Practice Address - Street 1:2094 ALBANY POST RD
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:NY
Practice Address - Zip Code:10548-1454
Practice Address - Country:US
Practice Address - Phone:914-737-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY13152225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation TherapistGroup - Single Specialty