Provider Demographics
NPI:1780689877
Name:GONZALES, KARRIE SUZANNE (PT)
Entity Type:Individual
Prefix:
First Name:KARRIE
Middle Name:SUZANNE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 N LINCOLN ST
Mailing Address - Street 2:STE J
Mailing Address - City:DIXON
Mailing Address - State:CA
Mailing Address - Zip Code:95620-3260
Mailing Address - Country:US
Mailing Address - Phone:530-297-7524
Mailing Address - Fax:530-746-0442
Practice Address - Street 1:125 N LINCOLN ST
Practice Address - Street 2:STE J
Practice Address - City:DIXON
Practice Address - State:CA
Practice Address - Zip Code:95620-3260
Practice Address - Country:US
Practice Address - Phone:707-693-1644
Practice Address - Fax:530-746-0442
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 13201225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABH388ZMedicare PIN
CA0PT132010Medicare ID - Type Unspecified