Provider Demographics
NPI:1811361405
Name:GONZALES, MARIESA (DPT, BSHA)
Entity Type:Individual
Prefix:DR
First Name:MARIESA
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:DPT, BSHA
Other - Prefix:MISS
Other - First Name:MARIESA
Other - Middle Name:RALENE
Other - Last Name:BARBOSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2100 LOUISIANA BLVD NE STE 410
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5412
Mailing Address - Country:US
Mailing Address - Phone:505-724-4300
Mailing Address - Fax:505-724-4384
Practice Address - Street 1:2100 LOUISIANA BLVD NE STE 410
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5412
Practice Address - Country:US
Practice Address - Phone:505-724-4300
Practice Address - Fax:505-724-4384
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1268486225100000X
AZLPT-30112225100000X
NMPT2023-2307225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist