Provider Demographics
NPI:1629217815
Name:GONZALES, AMANDA NAOMI (MOT, OTR)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:NAOMI
Last Name:GONZALES
Suffix:
Gender:F
Credentials:MOT, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 VICTORIA LN STE 13
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-3228
Mailing Address - Country:US
Mailing Address - Phone:956-412-6060
Mailing Address - Fax:956-412-6070
Practice Address - Street 1:512 VICTORIA LN STE 13
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-3228
Practice Address - Country:US
Practice Address - Phone:956-412-6060
Practice Address - Fax:956-412-6070
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111197225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX676617OtherMEDICARE PART A
TX178709501Medicaid
TX0046NNOtherBLUE CROSS BLUE SHIELD
TX00994ZOtherMEDICARE PART B