Provider Demographics
NPI:1265657738
Name:GONZALES, ROSWALD (PT)
Entity Type:Individual
Prefix:
First Name:ROSWALD
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:ROSS
Other - Middle Name:
Other - Last Name:GONZALES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:2605 N LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2485 E WABASH ST STE 100
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IN
Practice Address - Zip Code:46041-9400
Practice Address - Country:US
Practice Address - Phone:765-659-7400
Practice Address - Fax:765-659-7408
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006526A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200371550Medicaid