Provider Demographics
NPI:1225750896
Name:GONZAGA, VICTORIA BACALARES
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:BACALARES
Last Name:GONZAGA
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 1:8 NORWOOD CT
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-2122
Mailing Address - Country:US
Mailing Address - Phone:646-478-6772
Mailing Address - Fax:
Practice Address - Street 1:8 NORWOOD CT
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-2122
Practice Address - Country:US
Practice Address - Phone:646-478-6772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012431-012251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Single Specialty