Provider Demographics
NPI:1679693683
Name:GONZALEZ, KATHERYN AMPON (RPT)
Entity Type:Individual
Prefix:MISS
First Name:KATHERYN
Middle Name:AMPON
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2007 DODGE ST
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-1814
Mailing Address - Country:US
Mailing Address - Phone:727-481-1694
Mailing Address - Fax:727-535-5856
Practice Address - Street 1:4760 EAST BAY DR SUITE D
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-1814
Practice Address - Country:US
Practice Address - Phone:727-481-1694
Practice Address - Fax:727-474-4985
Is Sole Proprietor?:No
Enumeration Date:2007-03-31
Last Update Date:2018-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0012196225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL887450696Medicaid
FL887450600Medicaid
FLY041ABMedicare ID - Type UnspecifiedPHYSICAL THERAPIST