Provider Demographics
NPI:1609028281
Name:GONZALES, TARIN (PT)
Entity Type:Individual
Prefix:
First Name:TARIN
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:PT
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 896
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:NM
Mailing Address - Zip Code:87015-0896
Mailing Address - Country:US
Mailing Address - Phone:505-286-7838
Mailing Address - Fax:
Practice Address - Street 1:1 LINNIE CT
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015-9125
Practice Address - Country:US
Practice Address - Phone:505-286-7838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3552225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist