Provider Demographics
NPI:1033362108
Name:GONZALES, IRENE (LMP)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:486 WESTBOURNE LOOP
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:WA
Mailing Address - Zip Code:99323-9575
Mailing Address - Country:US
Mailing Address - Phone:509-539-7730
Mailing Address - Fax:
Practice Address - Street 1:4001 KENNEDY RD STE 12
Practice Address - Street 2:
Practice Address - City:WEST RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99353-7353
Practice Address - Country:US
Practice Address - Phone:509-539-7730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-02
Last Update Date:2008-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60020030225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist