Provider Demographics
NPI:1235773987
Name:GONZALEZ, MICHAEL BENJAMEN (CMT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BENJAMEN
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3970 ARIZONA ST APT 4
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-8815
Mailing Address - Country:US
Mailing Address - Phone:408-887-3597
Mailing Address - Fax:
Practice Address - Street 1:3970 ARIZONA ST APT 4
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-8815
Practice Address - Country:US
Practice Address - Phone:408-887-3597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46475225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist