Provider Demographics
NPI:1306404967
Name:GONZALEZ, TAISHA (LAC)
Entity Type:Individual
Prefix:
First Name:TAISHA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:277 MARTINE AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10601-3401
Mailing Address - Country:US
Mailing Address - Phone:914-222-5644
Mailing Address - Fax:
Practice Address - Street 1:277 MARTINE AVE STE 207
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-3401
Practice Address - Country:US
Practice Address - Phone:914-222-5644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006118-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist