Provider Demographics
NPI:1629147467
Name:GONZALES, LILLIBETH (PTA)
Entity Type:Individual
Prefix:
First Name:LILLIBETH
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 1:1250 WATERS PL
Mailing Address - Street 2:SUITE 501
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2720
Mailing Address - Country:US
Mailing Address - Phone:718-409-9444
Mailing Address - Fax:718-409-0236
Practice Address - Street 1:1250 WATERS PL
Practice Address - Street 2:SUITE 501
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2720
Practice Address - Country:US
Practice Address - Phone:718-409-9444
Practice Address - Fax:718-409-0236
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004682-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant