Provider Demographics
NPI:1275120941
Name:GONZALEZ, MAGNETA
Entity Type:Individual
Prefix:
First Name:MAGNETA
Middle Name:
Last Name:GONZALEZ
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 1:4737 MATILDA AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10470-1041
Mailing Address - Country:US
Mailing Address - Phone:917-561-7863
Mailing Address - Fax:
Practice Address - Street 1:4737 MATILDA AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10470-1041
Practice Address - Country:US
Practice Address - Phone:917-561-7863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028449225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist