Provider Demographics
NPI:1467253997
Name:GONZALEZ, CODY
Entity type:Individual
Prefix:MR
First Name:CODY
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 N 18TH DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85007-2432
Mailing Address - Country:US
Mailing Address - Phone:564-205-0930
Mailing Address - Fax:
Practice Address - Street 1:318 N 18TH DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-2432
Practice Address - Country:US
Practice Address - Phone:564-205-0930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-21
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty