Provider Demographics
NPI:1659703072
Name:GONZALEZ, JOSE MANUEL (BS,SLT)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:MANUEL
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:BS,SLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24875 CALLE MONTADERO
Mailing Address - Street 2:
Mailing Address - City:QUEBRADILLAS
Mailing Address - State:PR
Mailing Address - Zip Code:00678-7305
Mailing Address - Country:US
Mailing Address - Phone:787-452-7525
Mailing Address - Fax:
Practice Address - Street 1:CARRETERA 113 KM. 14.8
Practice Address - Street 2:SAN ANTONIO
Practice Address - City:QUEBRADILLAS
Practice Address - State:PR
Practice Address - Zip Code:00678-7305
Practice Address - Country:US
Practice Address - Phone:787-452-7525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR0021402355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR80004796168Medicaid