Provider Demographics
NPI:1710393483
Name:GONZALEZ, ANNETTE MARIE (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:MARIE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 STURDY RD
Mailing Address - Street 2:APT 102
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-5255
Mailing Address - Country:US
Mailing Address - Phone:219-309-0068
Mailing Address - Fax:
Practice Address - Street 1:512 STURDY RD
Practice Address - Street 2:APT 102
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-5255
Practice Address - Country:US
Practice Address - Phone:219-309-0068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001177A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer