Provider Demographics
NPI:1265262539
Name:GONZALEZ, ALEXA JULISSA (OTD, OTR/L)
Entity type:Individual
Prefix:DR
First Name:ALEXA
Middle Name:JULISSA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4640 WEDGEWOOD BLVD STE 101-105
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-7114
Mailing Address - Country:US
Mailing Address - Phone:240-457-9558
Mailing Address - Fax:
Practice Address - Street 1:4640 WEDGEWOOD BLVD STE 101-105
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-7114
Practice Address - Country:US
Practice Address - Phone:240-457-9558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD10329225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist