Provider Demographics
NPI:1518369479
Name:GONZALES, DENISE M (PTA-AIDE CMT)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:M
Last Name:GONZALES
Suffix:
Gender:F
Credentials:PTA-AIDE CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10149 ALTA BRISA WAY
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-9019
Mailing Address - Country:US
Mailing Address - Phone:818-602-9163
Mailing Address - Fax:
Practice Address - Street 1:10149 ALTA BRISA WAY
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-9019
Practice Address - Country:US
Practice Address - Phone:818-602-9163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-23
Last Update Date:2021-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37810225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist