Provider Demographics
NPI:1184007049
Name:GANZ, MARITESS GONZALES (PT)
Entity Type:Individual
Prefix:
First Name:MARITESS
Middle Name:GONZALES
Last Name:GANZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARITESS
Other - Middle Name:MALLARI
Other - Last Name:GONZALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3300 BOWMAN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129
Mailing Address - Country:US
Mailing Address - Phone:505-414-8158
Mailing Address - Fax:
Practice Address - Street 1:101 CALLAN AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577
Practice Address - Country:US
Practice Address - Phone:510-357-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38557225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist