Provider Demographics
NPI:1457854390
Name:GONZALEZ, RUBEN (PT)
Entity Type:Individual
Prefix:
First Name:RUBEN
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17919 MAGNOLIA BLVD APT 19
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3339
Mailing Address - Country:US
Mailing Address - Phone:909-746-7072
Mailing Address - Fax:
Practice Address - Street 1:860 VIA DE LA PAZ
Practice Address - Street 2:SUITE B-1
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272
Practice Address - Country:US
Practice Address - Phone:310-573-9553
Practice Address - Fax:310-573-9533
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA294530225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist