Provider Demographics
NPI:1477018281
Name:GONZALES, ARIEL (LPTA)
Entity Type:Individual
Prefix:
First Name:ARIEL
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40022 EATON ST APT 104
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-4511
Mailing Address - Country:US
Mailing Address - Phone:734-516-6677
Mailing Address - Fax:
Practice Address - Street 1:36137 WARREN RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-2027
Practice Address - Country:US
Practice Address - Phone:734-728-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001692225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant