Provider Demographics
NPI:1609120708
Name:GONZALES, ROXANNE (PTA)
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12431 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92841-3321
Mailing Address - Country:US
Mailing Address - Phone:888-475-5771
Mailing Address - Fax:888-475-5771
Practice Address - Street 1:12431 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841-3321
Practice Address - Country:US
Practice Address - Phone:888-475-5771
Practice Address - Fax:888-475-5771
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 9931225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant