Provider Demographics
NPI:1083140370
Name:GONZALEZ, DESIREE
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:GONZALEZ
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 1:4330 HOME AVE
Mailing Address - Street 2:
Mailing Address - City:STICKNEY
Mailing Address - State:IL
Mailing Address - Zip Code:60402-4314
Mailing Address - Country:US
Mailing Address - Phone:708-603-0384
Mailing Address - Fax:
Practice Address - Street 1:4330 HOME AVE
Practice Address - Street 2:
Practice Address - City:STICKNEY
Practice Address - State:IL
Practice Address - Zip Code:60402-4314
Practice Address - Country:US
Practice Address - Phone:708-603-0384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL217.000352235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist