Provider Demographics
NPI:1689120669
Name:ZENO GONZALEZ, IVELISSE MARIE (MASTER'S DEGREE)
Entity Type:Individual
Prefix:MISS
First Name:IVELISSE
Middle Name:MARIE
Last Name:ZENO GONZALEZ
Suffix:
Gender:F
Credentials:MASTER'S DEGREE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1608
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00970-1608
Mailing Address - Country:US
Mailing Address - Phone:939-630-1622
Mailing Address - Fax:
Practice Address - Street 1:20 CALLE M
Practice Address - Street 2:URB. CERRO REAL
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00969-4976
Practice Address - Country:US
Practice Address - Phone:939-630-1622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR004114-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist