Provider Demographics
NPI:1760771984
Name:GONZALES, SARA MARIA (BC-HIS)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:MARIA
Last Name:GONZALES
Suffix:
Gender:F
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-1017
Mailing Address - Country:US
Mailing Address - Phone:817-335-2583
Mailing Address - Fax:817-546-3672
Practice Address - Street 1:2001 E LOHMAN AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3167
Practice Address - Country:US
Practice Address - Phone:575-523-0267
Practice Address - Fax:575-523-6408
Is Sole Proprietor?:No
Enumeration Date:2011-03-29
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM638237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist