Provider Demographics
NPI:1184193187
Name:GONZALEZ, CORINNE
Entity Type:Individual
Prefix:
First Name:CORINNE
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 1:4560 SE INTERNATIONAL WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-4628
Mailing Address - Country:US
Mailing Address - Phone:702-417-2717
Mailing Address - Fax:
Practice Address - Street 1:6351 N FORT APACHE RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-2300
Practice Address - Country:US
Practice Address - Phone:702-515-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVOTA-2159224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty