Provider Demographics
NPI:1437411238
Name:GONZALEZ, DIANA C
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:C
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 1:13937 S SPRAGUE LN
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-7863
Mailing Address - Country:US
Mailing Address - Phone:385-308-8034
Mailing Address - Fax:
Practice Address - Street 1:250 BAILEY RANCH RD STE 300
Practice Address - Street 2:
Practice Address - City:ALEDO
Practice Address - State:TX
Practice Address - Zip Code:76008-3237
Practice Address - Country:US
Practice Address - Phone:682-593-3237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3111710225100000X
TX1219777225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0944746-02Medicaid
TX0031DGOtherBLUE CROSS BLUE SHIELD
456890Medicare Oscar/Certification