Provider Demographics
NPI:1114646924
Name:GONZALEZ, RICHARD (CMT, NMT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:CMT, NMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7641 RESEDA BLVD UNIT 93
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-2829
Mailing Address - Country:US
Mailing Address - Phone:818-913-2341
Mailing Address - Fax:
Practice Address - Street 1:7641 RESEDA BLVD UNIT 93
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-2829
Practice Address - Country:US
Practice Address - Phone:818-913-2341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72928225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist