Provider Demographics
NPI:1619378429
Name:GONZALES, GRACIELA YVONNE
Entity Type:Individual
Prefix:
First Name:GRACIELA
Middle Name:YVONNE
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 1:305 NEBRASKA ST # 820
Mailing Address - Street 2:BUSINESS TOWER 1, SUITE 200
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-3246
Mailing Address - Country:US
Mailing Address - Phone:817-292-8787
Mailing Address - Fax:817-789-6849
Practice Address - Street 1:1505 CALLE DEL NORTE
Practice Address - Street 2:SUITE 440
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-6036
Practice Address - Country:US
Practice Address - Phone:956-722-6221
Practice Address - Fax:956-722-6275
Is Sole Proprietor?:No
Enumeration Date:2014-09-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2105635225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant