Provider Demographics
NPI:1972656932
Name:GONZALES, MARIE A (LAC ,MS)
Entity Type:Individual
Prefix:MS
First Name:MARIE
Middle Name:A
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LAC ,MS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:82 LEGION PL
Mailing Address - Street 2:
Mailing Address - City:CLOSTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07624-2518
Mailing Address - Country:US
Mailing Address - Phone:201-767-9091
Mailing Address - Fax:201-767-3133
Practice Address - Street 1:196 MAIN ST
Practice Address - Street 2:STORE FRONT
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-2450
Practice Address - Country:US
Practice Address - Phone:845-398-1312
Practice Address - Fax:201-767-3133
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY000649171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist