Provider Demographics
NPI:1750826392
Name:GONZALEZ, ERIC (PTA, CPT)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PTA, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 S 4TH AVE
Mailing Address - Street 2:FLOOR 2
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08904-2620
Mailing Address - Country:US
Mailing Address - Phone:917-684-5080
Mailing Address - Fax:
Practice Address - Street 1:10 PARSONAGE RD
Practice Address - Street 2:5TH FLOOR, SUITE 500
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-2429
Practice Address - Country:US
Practice Address - Phone:917-684-5080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-05
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00324300225200000X
NY009807-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant