Provider Demographics
NPI:1336621887
Name:GONZALEZ, JOE A
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:A
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JOE
Other - Middle Name:ANTHONY
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:11109 MAYFIELD DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78410-2827
Mailing Address - Country:US
Mailing Address - Phone:512-800-2897
Mailing Address - Fax:
Practice Address - Street 1:1855 CHEYENNE DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-2201
Practice Address - Country:US
Practice Address - Phone:972-394-7191
Practice Address - Fax:972-492-5534
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211747224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant