Provider Demographics
NPI:1609341296
Name:GONZALES, DESIREE EILEEN
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:EILEEN
Last Name:GONZALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 RED BLUFF RD APT 70
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77503-3344
Mailing Address - Country:US
Mailing Address - Phone:832-997-2653
Mailing Address - Fax:
Practice Address - Street 1:3500 RED BLUFF RD APT 70
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77503-3344
Practice Address - Country:US
Practice Address - Phone:832-997-2653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT127598225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist