Provider Demographics
NPI:1659911204
Name:BECERRIL-GONZALEZ, MARY BENY (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BENY
Last Name:BECERRIL-GONZALEZ
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15430 FOUNDERS LN APT 234
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-6182
Mailing Address - Country:US
Mailing Address - Phone:952-380-6196
Mailing Address - Fax:
Practice Address - Street 1:2211 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1350
Practice Address - Country:US
Practice Address - Phone:612-330-1008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-12
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
MN390200000X
MN34012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program