Provider Demographics
NPI:1083955397
Name:GONZALEZ, CONNIE MARIE (MSCCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:MARIE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11053 E TRIPOLI AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-8562
Mailing Address - Country:US
Mailing Address - Phone:321-228-6785
Mailing Address - Fax:
Practice Address - Street 1:127 CARTER ST
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-3753
Practice Address - Country:US
Practice Address - Phone:912-756-6131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-12
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007167235Z00000X
AZ10913235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist