Provider Demographics
NPI:1275566762
Name:GONZALEZ-KING, BLANCA ZITA (PT, CHT)
Entity Type:Individual
Prefix:MRS
First Name:BLANCA
Middle Name:ZITA
Last Name:GONZALEZ-KING
Suffix:
Gender:F
Credentials:PT, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2171 NORTHLAKE PKWY
Mailing Address - Street 2:SUITE 118
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4104
Mailing Address - Country:US
Mailing Address - Phone:770-934-5712
Mailing Address - Fax:770-934-5728
Practice Address - Street 1:2171 NORTHLAKE PKWY
Practice Address - Street 2:SUITE 118
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4104
Practice Address - Country:US
Practice Address - Phone:770-934-5712
Practice Address - Fax:770-934-5728
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10912251H1200X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GRP4845Medicare ID - Type UnspecifiedMEDICARE GROUP #
P77312Medicare UPIN