Provider Demographics
NPI:1396928487
Name:GONZALEZ, MARY THERESA (RN)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:THERESA
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940-2214
Mailing Address - Country:US
Mailing Address - Phone:215-860-0629
Mailing Address - Fax:215-860-0629
Practice Address - Street 1:128 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-2214
Practice Address - Country:US
Practice Address - Phone:215-860-0629
Practice Address - Fax:215-860-0629
Is Sole Proprietor?:No
Enumeration Date:2007-12-11
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN256859L163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
83-07571OtherEVERCARE
GO509036OtherHORIZON BLUE SHIELD
83-07571OtherEVERCARE
GO509036OtherHORIZON BLUE SHIELD
073385Medicare PIN
509036R3WMedicare PIN