Provider Demographics
NPI:1194000745
Name:GONZALEZ, PABLO SR (MASSAGE THERAPY)
Entity Type:Individual
Prefix:MR
First Name:PABLO
Middle Name:
Last Name:GONZALEZ
Suffix:SR
Gender:M
Credentials:MASSAGE THERAPY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2613 SW 143RD AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-6583
Mailing Address - Country:US
Mailing Address - Phone:786-444-6695
Mailing Address - Fax:
Practice Address - Street 1:2613 SW 143RD AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-6583
Practice Address - Country:US
Practice Address - Phone:786-444-6695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA64616261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)