Provider Demographics
NPI:1508243635
Name:GONZALEZ, INES ILEANA
Entity Type:Individual
Prefix:
First Name:INES
Middle Name:ILEANA
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 1:1109 MAZZETTI RD
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-8629
Mailing Address - Country:US
Mailing Address - Phone:347-665-2507
Mailing Address - Fax:
Practice Address - Street 1:1109 MAZZETTI RD
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-8629
Practice Address - Country:US
Practice Address - Phone:347-665-2507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency