Provider Demographics
NPI:1598196388
Name:GONZALES, JODI C (ATR, NCC)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:C
Last Name:GONZALES
Suffix:
Gender:F
Credentials:ATR, NCC
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:
Other - Last Name:GONZALES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPCIT
Mailing Address - Street 1:5210 E PIMA ST STE 200
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-3678
Mailing Address - Country:US
Mailing Address - Phone:815-787-2587
Mailing Address - Fax:
Practice Address - Street 1:5210 E PIMA ST STE 200
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-3678
Practice Address - Country:US
Practice Address - Phone:815-787-2587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-05
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist