Provider Demographics
NPI:1558426817
Name:GONZALEZ, EMMANUEL (LPTA)
Entity Type:Individual
Prefix:MR
First Name:EMMANUEL
Middle Name:
Last Name:GONZALEZ
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:PO BOX 333
Mailing Address - Street 2:
Mailing Address - City:AGUA DULCE
Mailing Address - State:TX
Mailing Address - Zip Code:78330-0333
Mailing Address - Country:US
Mailing Address - Phone:361-998-2317
Mailing Address - Fax:
Practice Address - Street 1:2500 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ALICE
Practice Address - State:TX
Practice Address - Zip Code:78332-4169
Practice Address - Country:US
Practice Address - Phone:361-661-8130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2053187225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2053187OtherPTA LICENSE