Provider Demographics
NPI:1225068158
Name:GONZALEZ, KEVIN LUIS (PT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:LUIS
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 WYCKOFF RD
Mailing Address - Street 2:
Mailing Address - City:EATONTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-1840
Mailing Address - Country:US
Mailing Address - Phone:732-544-0007
Mailing Address - Fax:732-544-0008
Practice Address - Street 1:158 WYCKOFF RD
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-1840
Practice Address - Country:US
Practice Address - Phone:732-544-0007
Practice Address - Fax:732-544-0008
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA 06161225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist