Provider Demographics
NPI:1740800861
Name:GONZALEZ, MARCO (LMT)
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12508 FAIR LN
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75036-3728
Mailing Address - Country:US
Mailing Address - Phone:785-307-3384
Mailing Address - Fax:
Practice Address - Street 1:15790 DOOLEY RD STE 200
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-5722
Practice Address - Country:US
Practice Address - Phone:785-307-3384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-18
Last Update Date:2020-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT133361225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty